Brave New World: American midwives & obstetricians finally on the same (winning!) team ~ How, What, When & Why

by faithgibson on September 2, 2016

in 21st Century Healthcare in US, AB1308, new regs & new legislative efforts

streetart

ACOG Committee Opinions #669 & 664 make for strange but welcome bedfellows!

GOOD NEWS!

I am extreame encouraged by the recent and unexpected turn of event in the political saga between ACOG and Ca LMs.  ACOG’s two newest  Committee Opinions on PHB (#669) and a pregnant woman’s right to refuse medical recommendations (#664) are an answer to our prayers.

Clearly, these ACOG policy statements are nothing less than revolutionary. This situation is the perfect push-off point for a public education campaign that uses YouTube videos to tell this important story.

Our immediate goal is for childbearing women to have their own personal copy of ACOG’s committee opinion #664. Every pregnant woman — in fact, each and every citizen — needs to understand that the legal and ethical role of all birth attendants — obstetricians, other categories of physician, and midwives — is to provide information about the risks and benefits of whatever intervention they are recommending, and the appropriate role of the childbearing woman, in conjunction with her family, is to consider that information and make the final decision. 

Work-n-progress — 09-09-2-16 Our long-range goal is nothing less than rehabilitating our system of maternity care for healthy CB women with normal pregnancies. This must begin by reintroducing the principles of physiological support and management  and in the relationship between professional midwives mainstream health care and midwifery. For the last hundred years 

nothing less than a substantial rehabilitation of the system for providing maternity care for healthy CB women and in the relationship between professional midwives mainstream healthcare and midwifery. For the last hundred years 

Opinion 669 (PHB) actually discusses how to plan for a safe OOH birth — rather than attempting to scare the bejesus out of anyone who dares to consider it. Opinion 664 acknowledges the right of pregnant women to decline medical recommendations, or as is more often the case, to make medically-unpopular decisions without the obstetrician or hospital attorney threatening to get a court order. Obviously, this also applies to choosing mfry care & planning an OOH birth.  

It’s very fortuitous for us that ACOG has again publicly acknowledged the critically important principles of self-determination for childbearing women. Now these laudable, but abstract, principles must be turned into policies with practical application at the level that obstetrical care is provided — doctors’ offices and hospital obstetrical departments. We will be providing lots reasons to believe that doing this is in the best interest of the obstetrical profession.  

ACOG opinions #669 and #664 are the key to a new and improved relationship btw the obstetrical profession and California mothers and midwives. 

images-26

As current leader of the California College of Midwives, we are collectively using the idea of a “Brave New World” to describe a new relationship btw obstetrics and midwifery, one in which obstetricians and midwives see one another as playing on the same team and working together to achieve many of the same goals.

I honestly didn’t expect that I would live long enough to see obstetricians and California licensed midwives develop a truly professional relationship with each other.  And in fact, it has been a really rough ride, as those who know my story can imagine.

Politically-speaking, things have gotten demonstrably worse in the last 5 years. Several very openly anti-OOH members has been appointed to the Medical Board. Then in 2013 ACOG’s District IX (California and other west coast states) was able to use its considerable political influence to add unwanted and unwelcome amendments the LMPA.

The Licensed Midwifery Practice Act of 1993 was passed 23 years ago and yet District IX ACOG, with a few notable and much-appreciated exceptions, has remained something of a bully at the level of state politics throughout those 2 decades. The undeniable evidence is that our most recent amendment to the LMPA was sponsored not by midwives but by ACOG. AB 1308 significantly reduced our scope of practice and repealed the Standard of Care for California Licensed Midwives (SCCLM). Anyone familiar with the core documents of the ICM (International Conference of Midwives), will realize that both of these actions by ACOG violate the principle of autonomy for the profession of midwifery. 

From 1993 to 2013, the LMPA required CaLMs to consult, refer or transfer care if mother or baby developed a clinically significant complication. For twenty years, that worked very well for everyone — mothers, midwives, and the obstetrical community. But after AB 1308 went into effect in 2014, totally healthy midwifery clients who have an identified risk factor, or who fall into a category described in law as having or developing:any deviation from normal”, are required to be examined and evaluated by an obstetrically-trained physician before Ca LMs are allowed to provide (or continue providing) care.   

If however the mother-to-be refuses physician care (can’t find or afford, suffers from PTSD from physical or sexual abuse, or previous difficult birth, etc), Ca LMs cannot legally provide primary care or childbirth services. These families are forced into medicalized hospital births that often include an unwanted Cesarean. It’s particularly problematic when women want a VBAC, have an LGA baby or are post-term — all situations that are likely to require advanced skills of a professional.  Instead this newest amendment forces such families who want to avoid unwanted medicalization to find a lay midwife or have an unattended birth under circumstances when midwifery skills are most likely to be needed. Mind you, this was all done in the name of ’safety’. {information on increased in morbidity and mortality in unattended births}

In spite of ACOG’s historic hostility and its contemporary refusal to notice, maternity care for healthy women changed since 1910 and that process will continue. Eventually the US will adopt the same model of care already used by wealthy countries around the world. The word for this is “paradigm shift”, but in this case, the critical action is past tense — the paradigm has already shifted.

How and when did this seismic shift happen? Over the last decade, the high-profile, often nasty resistance to OOH midwifery care from organized medicine (AMA, ACOG, etc) , and several very questionable studies undertaken or unwritten by the obstetrical profession (Pang et al, Wax et al, Grünebaum et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting)

The jig is up — Netherland, UK, Canada all have integrated, mutually cooperative HC system, autonomously mfry professional and the right of parents to have the final say is all well established and (drumroll please — the have great outcomes, far better than ours as measured by low intervention rate, low M&M for mothers and babies AND high marks by childbearing families for satisfaction.

Now it is up to ACOG to decide if they want to lead, follow or get out of the way. 

To help bring this about, we are developing a two-pronged strategy that is more like a one-two punch — first we use friendly persuasion (Jan 1st to Dec 31st 2017). If that doesn’t do the job, we take of off our kid gloves and give them a “Godmother” reason to be reasonable. 

Any of the three are OK with me, as long as we wind up with a physiologically-based maternity care system for healthy women that is consistent with midwifery as practiced in the Netherlands, UK and Canada. This describes a mfry profession that is autonomous, and a childbearing population that is acknowledge to be self-determining within a system of fully informed consent and unfettered access to comprehensive perinatal services as needed.       

I know that it seems unlikely that ACOG would EVER in a hundred million years allow this to happen. Nonetheless-the-less, I think the smart money is on ACOG finally acknowledging that midwives and OOH birth are never, ever going to go away and followed up by a grudging recognition of mutual interests and a reluctant (but realistic) decision to cooperate within the circumscribed arena of a pregnant woman’s right to make medically unpopular choices after being fully informed. 

There is a subtle synchronicity with the way Americans made first accepted racial integration by reluctantly acknowledging the constitutional right of black Americans to the same civil right and/or human dignity as all other American citizens. Accepting their right to civil protection didn’t mean you had to be friends with them, invite them over to dinner, or offer your daughter in marriage. 

The change of perspective inherent in Opinions 669 & 664 gives ACOG a chance to take credit for being a leader in this area. Since ACOG advertises itself as the nation’s leading provider of women’s reproductive health care, it’s only fitting that they should actively represent “a woman’s right to choose”, whether that is to terminate an unwelcome pregnancy or a right of bodily integrity, as in saying ‘no’ to unwanted obstetrical interventions. 

Unfortunately for them, their only other option is to be dragged kicking and screaming into acknowledging the obvious and the inevitable — that physiologic childbirth practices are the science-based, cost-effective standard of care for healthy women w/ normal pregnancies used in developed countries all over the world. 

While obstetricians could decide to provide supportive, non-interventive care to healthy women having a normal labor, the better part of valor (more cost-effective and wisest choice) is for doctors to do the doctoring, while they leave the midwifing to midwives. 

Within a functional healthcare system, physiologically-based care, whether provided by midwives or other types of birth attendants, gets high marks for goods outcomes with a very low level of medical or surgical interventions. This not only eliminates unproductive expense but reduces iatrogenic and nosocomial complications and re-hospitalizations, a fact appreciated by healthcare system all over the world. 

As a result, the 19th thinking behind 20th century American obstetrics can no longer endure in a global community that figured out long ago that medicalizing healthy women was counterproductive.  Its the difference btw doing things to someone vs doing things for someone. For the last century and 2 decades into the next, women have been the non-sentient objects of the surgical specialty of obstetrics; the role of women was to lay still while the doctor did something to you. The two ACOG committee opinions acknowledge that such a model is outmoded and should be laid to rest.          

From that perspective ACOG has provided a perfect opportunity for us to publicly highlight and ultimately reverse an unfortunate state law that forces certain categories of essentially healthy childbearing women into non-consensual forms of care under a new, ACOG-sponsored amendment to the 1993 California Licensed Midwifery Practice Act. 

To correct this problem, we plan on creating a helpful informed public opinion to aid us in re-establishing the legal authority of Ca LM to provide (or continue providing) care women with identified risk factors (such as LGA babies, VBAC or post-term) who have refused transfer to obstetrical services and been fully informed of any increased risks associated with their specific circumstance.

Our plan begins with a year-long series of brief (3 to 10 minute) but informative YouTube video discussions that I refer to as “Teddy Talks”. The first 3 are about ACOG new opinions #669 & 664, which are addressed in separate discussions, and then as a combined topic. We also encourage CaLMs to make copies of both Opinions and provide them to families interested in a midwife-attended OOH birth as part of an extended ‘informed consent’. 

This provides ACOG with an acknowledged area of common ground, since ACOG’s official position (based on studies done in the US, esp. Pang & Wax meta-analysis), shows an increased NNM for women planning to give birth in an OOH setting. According to Opinion 669, the NNM for low-risk births attended by obstetricians is 0.17 per 1,000. I read the reference used in its 669,  did not include this data and I have been unable to find any additional reference for such an extraordinarily low number. Nonetheless, it is four times lower than the NNM rate of CaLMs, which is 0.7 per 1,000 or a ratio of  1: 849 when birth defects are included and  1: 1,698 when anomalies are excluded. 

However, Ca LMs are quite happy to discuss why studies on PHB done in the US come to such different conclusion than those from the Netherlands, UK and Canada, and how we can make OOH care in US just as safe as it is in other developed countries. This matches perfectly with ACOG’s own public statement in Opinion #669, which address the issue of how to have a safe planned OOH birth.   

Equally fortunate for ACOG, we are not (presently) requiring them to admit to that obstetrically-attended hospital birth in the US is associated with a relatively high (and increasing) rate of maternal mortality. ACOG believes the data is flaw — a fluke caused by better reporting rather than an increase. Regardless, midwives don’t want to do anything that might make CB families distrustful of obstetricians or cause them reject necessary obstetrical services.    

Other timely and important topics include a discussion about pregnant women with a history of physical or sexual abuse and/or PTSD after a previous medicalized birth. There is a great deal to be said about why such women go to great lengths to avoid a subsequent medicalized childbirth, either by having a scheduled C-section or planning to labor OOH labor birth with a midwife in attendance. I’ve noticed that a normal labor naturally leads to a normal spontaneous birth  

This topic is will be presented in three parts and include a discussion of mfry licensing laws in California that create a “denial of services” when these women also have certain an identified obstetrical risk. Another segment explores unattended OOH birth and the extremely high level of preventable neonatal and maternal morbidity and mortality associated with not having any prenatal care and/or purposefully choosing an UN-attended labor and birth, a NNM rate that ranges from 30 to 120 deaths per 1,000 [ref: Outcomes of home birth in North Carolina, Burnett, et al JAMA, 1980).  

My favorite and our most unusual topic will be the new scientific evidence on the effect of physical body posture on whether we succeed or fail in important areas of our lives, such as passing important tests (college entrance exams), critical job interviews and other personal and professional achievement that matter greatly to us and may have long term impact on our lives. 

Spoiler alert — while not part of the original research, one of the potential “achievements” in this category would be a spontaneously progressive labor and normal birth.  

Research recently published by Amy Cuddy in her book “Presence” reports that when test subjects in psychological experiments were asked to assume various passive, defensive and/or submissive positions or postures (slouching in their chair; staying very still and taking up as little space as possible w/ legs crossed, tucked under their chair, arms crossed tightly over their chest; leaning forward with elbows on knees, head hanging down and looking at the floor, etc), the test subjects reliably became psychologically restrained and frequently failed to speak up or act in their own behalf. 

After waiting for several minutes in such passive positions, these subjects all scored lower on tests, did not speak up when someone short-changed them, were unlikely be hired after a mock job interview, and at the end of the experiment, sat passively waiting for the researcher to return long after it became apparent that they’d been ‘forgotten’ (in this case purposefully). 

When the same and different test subjects were instructed to assume postures and positions that were the exact opposite — that is, confident postures such as standing or sitting tall, looking forward, moving around the room, leaning forward on their below while looking up, and my favorite — the starfish-up or “Wonder Woman” poly upward and thinking pleasing thought about oneself. 

This ‘Wonder Woman’ or ’starfish up’ posture is seen when an athlete wins a sporting event or someone wins a contest. These active postures were the exact opposite of passive and submissive position and so were the results of the experiment. Test subjects made higher than average test scores, got “hired” after the mock job interview, spoke up when someone cheated them, and at the end of the experimental session, only sat for 5 minutes before leaving their cubical to look for the researcher, who had promised to pay them for participating.  

In considering the typical hospital labor room in the US, we would see that 90% of its laboring women are tethered to a bed by IV lines, EFM cables, epidural infusion pumps, automatic blood pressure cuffs and pulse oximetry lead, foley catheter, and tubing that tethers a urine bag to the side of their bed.  Far top often these women have an oxygen mask over their face because the nurse was worried over some potential abnormality in the EFM tracing. Given these circumstances, it does not seem at all strange that most hospitals in the developed world have a Pitocin augmentation over 50%, an epidural rate as high as 95% in some communities, and Cesarean rate well north of 25%. 

Recently the California Maternal Quality Care Collaborative (CMQCC) spearheaded a campaign to promote vaginal birth (i.e. to lower the CS rate, particularly for healthy women with a single fetus in a vertex position). But this will be impossible as long as the obstetrical profession continues to NOT acknowledge that the mother-to-be’s psychology plays a big and important role in normal labor and spontaneous birth. The mother’s psychological status will ultimately determine whether she can allow herself to ease into a progressive labor pattern (and gives birth w/o incident), or suffers some version of ‘failure to progress’ that will ultimately require hospitalization and many medical and surgical interventions to remedy.   

But imagine for a minute how that labor room scene would be different if we applied the insight identified in the “Starfish-Up” experiments? What if we backed up to the prenatal phase and instructed women to practice the “Starfish-up/Wonder-Woman posture for at least 2 minutes every day of their pregnancy?

What if we took the hospital LDRP bed out of the middle of the room and encouraged the laboring woman (i.e., not L&D nurses or hospital midwives) to determine how she would conduct herself in labor — what she did, how she did it and where (including leaving the LDRP unit)  — all the while encouraging her to use active postures, positions and activities so that are the opposite of submissive or defensive positions?

Currently, the obstetrical profession in America is in a very unenviable position — a loose-loose situation in which the historical tradition of their surgical discipline glued a pair of boxing gloves on their hands and now society is daring them to perform the most delicate surgery with their hands bound up in big bulky gloves. 

They lack all the elements necessary for supporting the physiology of normal labor and birth. That would have required medical schools to include the principles of physiological management in their curriculum. Had that happened, obstetricians would appreciate just how strongly the mother’s psychological states influences the spontaneous onset of labor (negatively if PTL, positively if term) and whether or not labor become and remains progressive. If physiologically-based management were part of the medical education process, obstetrical residents would learn about drug-free pain relief strategies (therapeutic touch, hot showers, deep water tubs, etc). Making right use of gravity would be as normal a strategy as hand-washing or auscultating FHTs. 

Until and unless this occurs, it’s virtually impossible for the current hospital-based obstetrical unit to dramatically reduce their Cesarean delivery rates, no matter how hard or how long they try. 

Under such circumstances, the wise choice seems to be an alliance with midwives both as providers of physiologic birth services and as a category of individuals that can help to advance the obstetrical understanding of the mind-body connection in regard to pregnancy, labor, birth and new motherhood. In a perfect world, professional midwives and physician-obstetricians would think of themselves as playing different parts on the same team, like catchers, batters, and fielders on a baseball team — all are necessary, all contribute, all are appreciated.

Well, I’ve written quite enough for today. Hope it has informed and spurred the reader’s imagination.  

{ 0 comments… add one now }

Previous post:

Next post: