California College Of Midwives
{Work-n-Progress as original file incompatible with WordPress — changes all apostrophes to questions marks “?”}
February 10, 2003
TO: Dr Fantozzi, MD; Midwifery Task Force, Member – MBC
RE: Our organization’s official opposition to the MBC’s currently proposed midwifery Standard of Care (per SB 1950, Figueroa, 2002)
Other members of the California College of Midwives present at the Saturday, Feb 1st General Meeting reported that the Board’s formal position on the implementation of SB 1950 was quite different than the statement read during the Friday DOL meeting.
As described, the Board’s conclusion appeared to reflect the position of the two American College of Obstetricians & Gynecologists representatives who spoke on behalf of ACOG’s District IX. As we are all aware, ACOG’s position is that the hospital-transfer issue makes home-based birth care unacceptably dangerous.
In spite of the plain language in the legislative intent and body of the LMPA, ACOG spokesmen continue to act as if the MBC has a legal duty to restrict the care of professionally-licensed midwives and should use its authority to the promulgation of regulations restricting the practice of licensed midwives to acute-care hospitals and state licensed birth centers. They apparently read something in the black-letter law of SB 1950 that isn’t apparent to midwives and mothers.
Alone with the rejecting planed home birth services as provided by LMs, obstetricians also fight tooth and nail against granting hospital privileges to LMs. With rate exception, they refuse to serve as medial directors for free-standing birth centers, which are necessary for birth centers in California to operate.
However, the elimination of legal home birth practitioners would do much to re-create lay midwifery, revive practice under the religious exemptions clause and promote unattended labor and birth at home.
I must mention that as an L&D nurse, ACOG obstetricians were perfectly happy to leave their actively laboring patient in my care in the middle of the night in small community hospital with no in-house physician.
While these midwife-unfriendly doctors slept peacefully in their beds at home (minimum travel time of 10 to 20 minutes) I attempted to give my professional attention to women in four labor rooms and one OR, with the added responsibility of post-anesthesia recovery of newly delivered women and helping new mothers breastfeed for the first time.
Practically speaking, this meant that I was only able to be present with each laboring women for 3 to 7 minutes every 30 minutes to auscultate FHTs (or read the EFM strip), take vital signs and monitor progress via vaginal exams. I spent considerably more time with the chart than the patient.
I was usually out of the room for 45 minutes of every hour, either leaving the mother alone or in the care of lay persons such as a family member. (A recently published study on L&D nursing discovered that labor room nurses are out of the labor room 79% of the time.) By the time I (and other busy L&D nurses) detected fetal distress, a prolapsed cord or a PP hemorrhage and notified the obstetrician & anesthesiologist who had to dress and drive to the hospital, it was often at least as long (if not longer) than the typical hospital transfer of a midwifery client. And being out of the labor room for three-quarters of an hour, I had no idea how long the complication went undetected before this emergency response was put into play.
I notice that ACOG is perfectly comfortable with this on going situation.
In home-based midwifery care, the ratio of practitioner-to-patient is always one to one. The continuity of care in community-based midwifery is always an advantage. A skilled midwife is an educated observer with emergency response capacity. An unattended birth is always one in which there is no educated observer present and no has the capacity to effectively intervene in case of an emergency. I can’t imagine why ACOG would want to promote unattended home births by making professional midwives unavailable to childbearing women.
When emergent conditions arise, the midwife calls ahead (cell phones are a wonderful adjunct to this early warning system) and notifies the hospital so they can contact the doctor at home. By the time he dresses and drives to the hospital (the same 10 to 20 minutes), the patient, midwife and doctor often converge in the hallway on route to the labor room.
It is an interesting phenomenon that the same doctors who are outraged at the thought of mothers laboring at home are perfectly happy to be at home themselves while their patients labor at the hospital 20 minutes away in the care of over-worked and often inexperienced nurses.
Historic failures of the obstetrical profession to adequately and safely serve healthy women with normal pregnancies
The current controversies in community-based midwifery actually represent the failures of the obstetrical profession to adequately and safely serve healthy women with normal pregnancies.
This is not personal opinion but well-supported fact. This institutionalized inadequacy sets up childbearing women who have a normal pregnancy but also have an identified risks factors, such as breech, twin or post-Cesarean status, to reject the interventionist practices of obstetrical medicine. In an ideal world, these moderate-risk labors would be managed “physiologically” in a hospital by midwives under circumstances best described by the Dutch phrase “a relocated home birth”. This would truly be the best of both worlds — the successful use of time-test methods historically known as the “midwifery model of care” in conjunction with immediate access to all the technology of modern medicine and the technical expertise of obstetricians.
Organized medicine brought this crisis about in two very specific ways – a hundred year history of obstructing the independent practice of midwifery and attempting to criminalize its practice and their irrational enthusiasm for an interventionist model of care for healthy women despite its deleterious consequences for mothers and babies.
Organized medicine’s historical rejection of physiological management was formalized in the United States in 1910. It was accompanied by an aggressive campaign to eliminate the so-called “midwife problem” by eliminating midwives. The fallacious claim that “midwives kill babies” and doctors save them was the profession’s propaganda slogan. This clearly conflicted with all scientific evidence as reported by a few honest physicians of the time.
The uninformed testimony of the two ACOG reps at the Boards’ Task Force meeting just 3 days ago tells us that little has changed in the intervening 90-plus years. This is the reason there have been no professional midwifery training programs or state licensure of midwives for most of the last hundred years. It is also why, in contemporary times, we do not have a cost-effective, seamless and mainstream system of maternity care as enjoyed by Dutch mother in The Netherlands.
The second act of this drama as orchestrated by organized medicine is the shameless promotion of an ever increasing medicalization of normal labor which had dominated obstetrical practice for the last century.
This irrationality equals an unhistoric “flat earth obstetrics” that is keeps pushing and pushing the envelope until arriving at the most dangerous of all “labor-saving devices” — the medically-unnecessary, “maternal-choice” Cesarean surgery.
This predilection creates an ever-widening stream of maternal complications and preventable maternal mortality. It also fueled a backlash in which national organizations such an the International Cesarean Awareness Network (ICAN) have arisen and include many previous Cesarean mothers who are flatly declining medical advise for an elective repeat Cesarean.
These mothers have already experienced one or more highly medicalized hospital labors in which they were immobilized in bed with IV lines and a tangle of cords that lead to the continuous electronic fetal monitoring system. It did not end well for them and when I suggest a hospital VBAC, they say: “I refuse to return to the scene of the crime“, which is how they viewed their experience.
Women often identify the massive quantity of routine interventions and protocols that have become the hospital norm as the iatrogenic cause of their previous Cesarean and want no part of this repeat performance.
Over-treatment always has an equal or greater potential for resulting in serious complications and even maternal mortality as any type of “under treatment”. It is not automatically superior to suffer from over treatment and is especially tragic when the woman and her pregnancy was healthy to begin with and the problems were iatrogenic in origin.
ACOG has used it’s consider influence to make the American public pathologically afraid of normal childbirth, all out of proportion to the actual dangers to healthy women with appropriate access to our modern system of health care. This sets women up to be hysterical frightened by labor and seek out (or be advised by their doctor to seek out) inappropriately early hospitalization, long before the onset of progressive labor.
This iatrogenic problem is supposedly “solved” by the routine use of oxytocin to induce or augment latent labor. Artificially accelerated labor is exquisitely painful and leads almost inevitably to the need for an epidural. Anesthesia further slows labor, requiring IV Pitocin, which can and often does precipitates fetal stress. This means the mother must be put on oxygen, giving everyone the impression of great danger.
If the labor does not progress rapidly at that point, it sets up a situation that will frequently requires use of forceps or vacuum extraction or Cesarean delivery for fetal distress or “failure to progress”. However the real failure was obstetricians couldn’t or wouldn’t keep their Pitocin and other obstetrical toys for patients who really needed and benefited from them.
The bottom line is the failure to the obstetrical profession to teach, learn and utilize physiological management as the foremost standard for healthy women with normal pregnancies. This results in inappropriate medicalization (early hospitalization with IVs, Pitocin, artificial rupture of membranes, continuous electronic monitoring, epidural anesthesia) mechanization (forceps or vacuum extraction) and/or surgery such as episiotomy and Cesarean section.
This jeopardizes the well being of mothers and babies, increases maternal complications both during and after the birth such as infection, blood clots, pulmonary embolisms, hemorrhage, emergency hysterectomy and all the immediate, delayed and downstream complication in post-cesarean pregnancies, many of which are fatal. It represent a lack of due diligence for any professional birth attendant to be ignorant of these science-based realities, which are freely acknowledged by many individuals within the obstetrical and scientific community and available to anyone with the time or interest to google them on the Internet.
From the stand point of the Medical Board and its official activities as the regulatory body of both obstetricians and licensed midwives, it would be a lack of due diligence were its representatives to remain uninformed of these crucial facts and their influence on both the practice of LMs and the demands of the healthy childbearing public, which is unable to obtain safe and appropriate care from the obstetrical community in far too many instances.
It is my understanding that the legal obligation of the MBC is to license appropriately trained and qualified medical practitioners and to discipline these licentiates if they violate their professional standard of care.
For better or for worse, the Board itself does not at this time set standards for any profession under its authority. That determination occurs as a result of the expert review process by a bona fide member of the discipline in question.
Despite ACOG?s contrarian perspective, SB 1950 does not direct the medical board to define “safety” or propagate a midwifery standard of care on its own and separate from the community of licensed midwives. The legislative language uses the word “adopt”, not define or develop. While the original LMPA does not identify home birth as the sole or even central setting for intrapartum care, or otherwise address the “safety” of planned out-of-hospital (OOH) midwifery care. However, the 2000 Figueroa amendment (SB 1479) does defines the “midwifery model of care” and identifies that “home” as a safe choice for mothers based on access to professional, community-based midwifery care as intrinsic to the safety of the parents’ lawful choice of an OOH setting.
Were I in charge of how maternity care was offered by professional attendants in California, I would requires medical schools to teach midwifery as a historic and contemporary discipline and for ACOG to be sure that currently practicing obstetricians receive continuing education in the physiological management of labor and birth. I would insist that public pronouncements by ACOG and individual obstetricians that falsely promoted elective cesareans as the superior and safer choice for parents to be a false claim that equated to unprofessional conduct. At that point, I would expect the MBC to investigate and file disciplinary charges against these physicians.
I know this letter is unconsciously long and it content controversial, and for I apologize. However, the bottom line is actually quite simple. The MBC did not write the standard of care for the practice of obstetrics, because the rightful organization to propagate such a document is the members of the obstetrical profession themselves. The right organization to propagate a standard of care for the practice of community-based midwifery are professional licensed midwives themselves. I doesn’t get any simpler than that.
I thank you for you time. If you have any questions or comments, I may be reached by email at “faithgibson@mac.com”
Warm regards,
Faith Gibson, Ca LM 041