Easy to share link –> http://tinyurl.com/y3yeju59

An illegal action by California’s Sutter Health {Oct 2018} defined by NAFTA as an “disguised restriction of services

An unfair & illegal business practice by California state law B&P Code 17200 – 17209

Below is:

  • Transcript of  an official Obstetrical Consent Form dated 10/08/2018
  • Politician Action Plan for California Residents  

In addition to the lawful documentation of patient consent for obstetrical services, the Sutter Health document goes on to informs their maternity patients that OBs covered by Sutter Health will withdraw their professional services whenever they find out that parents are planning an out-of-hospital/home birth.

@@@@@@@@@@

Sutter Health
Sutter Gould
Medical Foundation

OBSTETRICAL CONSENT FORM

1400 E. Briggemore Ave
Modesto, CA 95355

Larry Erickson, MD
Jon Post, MD
Masid Liva, MD
WhitneyLaciair, DO
Wilson Sava, MD
Eduardo Malvin B. Laguna Jr, MD

I ________________, understand and agree that one of the above aed physician will deliver y baby. The physician on-call will normally deliver after hours and on weekends.

I also understand that the prenatal fee quoted includes only the physician’s fees for prenatal office visits, normal vaginal delivery, and postpartum care for two month after delivery. Our fees do not include laboratory fees, pap smear, medication and injections, colposcopy and cervical biopsy, genetic studies, ultrasonography, non stress and stress tests internal and external fetal monitoring during labor , circumcision of infant, Cesarean section, assists fee for sutry, postpartum tual ligation, dilatation and curettage or in-office pregnancy test.

This list is comprehensive but not necessarily all inclusive.

I understand and agree that one of the above named Physicians will deliver my baby. The physician on call will normally deliver after hours and on weekends.

I also understand that the prenatal fees quoted includes only physician fees for prenatal office visit, normal vaginal delivery and postpartum care for 2 months after the delivery.

Our fees do not include laboratory fees pap smear medications and injections colposcopy and cervical biopsy genetic studies Ultra sonography non-stress and stress test internal and external fetal monitoring during labor circumcision of infant cesarean section assistance fee for surgery postpartum tubal ligation dilatation and curettage and in office pregnancy test.

{{The following content in the original document is a single paragraph. However, I have separated each of the four sentences to clearly identify the illegal anti-PHB statements constitute an unlaw and “disguised restriction of services”relative to midwifery care.}}

Additionally, I have been informed that Sutter Gould Medical Obstetricians do not support delivery at home because of the risks to both the mother and the baby are markedly increased when babies are born at home.

Planned home births result in double the infant death rate, lower apgar scores, higher maternal bleeding and higher risks for needing blood transfusions compared to women who plan on delivering their babies at the hospital.

I am aware that my delivery will take place at the hospital with which my insurance is contracted. Most insurance companies do not cover home birth.

If I plan to birth outside of the hospital setting, I will inform my doctor my plans immediately.

I understand that I will need to transfer my care to another doctor in a different Medical Group if I plan on delivering my baby outside of the hospital.

I understand that it is my responsibility to know whether or not my insurance company requires prior authorization for delivery if so I will let the assistant know in order for them to obtain prior authorization.

Patient signature __________________

Witness ________________________

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Political Action For California Residents:

Below are simple, step-by-step Instructions for writing a one (or at most, 1 1/2) page letter to California’s new insurance commissioner, Ricardo Lara.

I double-dare every single LM on the Google group email to write a letter. I certainly plan on doing so myself.

Letters should include a “cc” at the bottom, noting that copies of your letter and accompanying documentation are also being sent to the Medical Board of California and California Association of Licensed Midwives (CALM).

This notifies Commissioner Lara (via senior staff who reads the mail), that this issue is also being brought to the attention of the MBC and the state organization for California licensed midwives.

I encourage mothers and midwives living in the Sacramento to also “cc” the Sacramento Bee and likewise forward a of their letter to the newspaper. (address also below)

If CALM is currently working with a midwifery-friendly State Legislator, his or her senior assistant should get a copy of Sutter Health’s document and be informed about this grass-roots letter-writing campaign.

Where to begin:

(1) Copy the contents of this Sutter Health OB consent form into a WORD document and then print it out.

(2) Compose a one- (or 1 1/2) page cover-letter using this or a similar template for communicating with legislators and state regulators:

After typing the date, your address and that of the California DCA ~ Insurance Commissioner (full address below), use a “Regarding” (i.e., RE:) that quickly identifies the topic, some version of:

RE: Unlawful actions by Sutter Health targeting out-of-hospital birth services:

Enclosed copy of Oct 2018 Sutter document that refuses to provide OB prenatal care or childbirth services to pregnant women insured under the Sutter Health plan who are receiving concurrent care for a planned OOH birth, from a California licensed professional midwife (CNM or LM)

Then identify yourself in a sentence that includes (a) your age and gender, (b) length of California residency, and (c) your demographic category — concerned citizen, childbearing woman, parent, grandparent, midwife or other HC professional, and/or community-activist, etc.

In a sentence or two, explain why you believe Sutter Health’s policy is anti-competitive {{ California’s “Unfair Competition” law is B&P Code 17200 – 17209}} and violates the law and that you also find Sutter’s policy offensive on ethical and/or constitutional grounds. (see definition of B&P Code 17200 below that would apply to statements and scare tactics  used in the OB consent form.

(Examples: That Sutter’s stated policy drastically misrepresents the facts in relation to safety; the right of self-determination that applies to all mentally-competent adults regardless of gender, high CS rate associated with hospital-based obstetrics for healthy childbearing women and its associated dangers including significant increase in maternal morbidity and mortality, the unaffordability for those without health insurance or who have high co-pays, etc )

You can provide two examples, one that is more complex and includes informative statistics (quotes from MANA, LMAR, Childbirth Connection,  “Listening to Mothers Survey“, other published studies, etc) and a second topic that addresses issues such as the cost of EFM in light of the scientific literature, including ACOG’s 2003 Task Force on Cerebral Palsy and other studies that concluded (Female Patient April 2011):

“Despite the widespread use of EFM, there has been no decrease in cerebral palsy. … meta-analysis of randomized control trials has shown that EFM has no effect in perinatal mortality or pediatric neurologic morbidity.2 However, EFM is associated with an increase in the rate of operative vaginal and cesarean deliveries.1”

State that your letter represents a formal request to the California Department of  Insurance investigate your complaint against Sutter Health for violation of B&P Codes 17200-17209.  

End with something like:

“Thanking you in advance for attending to my complaint. I’m looking forward to a reply from CDI within the next 60 days

At the very end (after your signature), be sure to type in the lower case letters  “cc”, and list the agencies and organizations that you will be mailing xeroxed copies of both your letter and the Sutter Health OB Consent document.

Don’t forget to email a copy to Rosanna Davis, president, CALM.

 

 

 

MAILING ADDRESSES & REFERENCE MATERIALS 

B&P Code 172000 @@@@@@@@@@@@@@@@@

California’s “Unfair Competition” Law. (Business & Professions Code 17200 – 17209) California’s “unfair competition” law prohibits false advertising and other anti-competitive practices. Lawsuits can be brought by either consumers or by businesses that have been damaged by a competitor’s unfair actions.

California Business & Professions Code §17200 prohibits any “unlawful, unfair or fraudulent business act or practice” and any “unfair, deceptive, untrue or misleading advertising.”Jul 12, 2017

EFM @@@@@

Quotable materials on the utter failure of policy mandating use of continuous EFM on healthy women with normal pregnancies and it’s high human and economic costs

http://tinyurl.com/y3ty2392 ~ The False Association btw the routine use of continuous electronic fetal monitoring (c-EFM) to prevent Cerebral Palsy, Maternal Pelvic Floor Damage & Protect OBs from Lawsuits ~ Part 1 (of 3)

@@@@@ ADDRESSES  for CDI & MBC @@@@@@@

California Department of Insurance
Contact Us

Hotline Telephone Numbers

Consumer Hotline…………………………………. 1-800-927-4357 (HELP)
1-800-482-4833 (TTY)
or send us an email
Licensing Hotline………………………………….. 1-800-967-9331
California Low Cost Automobile Program.. 1-866-602-8861

 

CDI Headquarters Offices

Sacramento Office
300 Capitol Mall, Suite 1700
Sacramento, CA  95814

San Francisco Office
45 Fremont Street, 23rd Floor
San Francisco, CA 94105

Los Angeles Office
300 South Spring Street, South Tower
Los Angeles, CA 90013
@@@@ MBC @@@@

THE MEDICAL BOARD OF CALIFORNIA
2005 EVERGREEN STREET, SUITE 1200
SACRAMENTO, CA 95815

Email Us Please include your full name and, if applicable, your license number so we can better assist you

webmaster@mbc.ca.gov

@@@@@ Sac Bee @@@@

Main Office
The Sacramento Bee
2100 Q. St.
Sacramento, CA, 95816
Telephone:
(916) 321-1000

www.sacbee.com.

 

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https://tinyurl.com/ydcmxlkv

 ACOG Committee Opinions #166 and #214, the 2000 Amendment (SB 1479) to the LMPA of 1993 and the midwifery Standard of Care ~

Limitations imposed by AB 1308 in 2013 that repealed the standard of care and statutorily denied ‘patient autonomy’ and ‘self-determination’ to essentially healthy childbearing women

The Standard of Care for California Licensed Midwives (SCCLM) was legislatively authorized by Senate Bill 1950 in the year 2002, adopted by the MBC in September 2005 and formally approved and published as a legally-binding regulation by the Office of Administrative Law (OAL) in March 2006.

The licensed midwife who compiled the final version of the Standard of Care in 2004 used ACOG Committee Opinions #166 and #214 as a guide for developing the legal principle that defined childbirth-related consent (i. e., that no one can touch or treat a competent adult without the adult’s informed consent) –when developing Section V of the Standard – The Responsibilities of the Licensed Midwife and the Client’s Right of Self-determination.

The result was these two short statements that defined the ethical and legally-binding relationship between professional midwives and California childbearing families from March 6th, 2006 to January 1st, 2014.

They read:

Responsibilities of the Licensed Midwife

With respect to the care of a client with a significant risk factor as identified by the client-selection criteria in section IV, other science-based parameters or physical examination, the licensed midwife shall recommend that her situation be evaluated by a licensed physician who has current training and practice in obstetrics.

Client’s Rights to Self-Determination

In recognition of the client’s right to refuse that recommendation, as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available to her, make a written informed refusal.

If the licensed midwife appropriately documents the informed refusal in the client’s midwifery records, the licensed midwife may continue to provide midwifery care to the client consistent with evidence-based care as identified in this document and the scientific literature.

In addition to the ACOG Opinions, the “Intent” language in SB 1479 was also used to craft this ‘state of the art’ description of the legal duties of the LM and the legal rights of the client. SB 1479, which is the second amendment to the LMPA, provided a ‘legislative remedy’ that addressed a problematic ruling in a California Supreme Court ‘Stare Decisis” case in 1976.

In Bowland v. Municipal Court, the Supreme Court noted that California childbearing women had no established right to make decisions about the type of care they received during pregnancy and childbirth. The opinion went on to say that the State Legislature had “never gone so far” as to acknowledge that, as a class, healthy childbearing women had the right to choose “the manner and circumstances of normal childbirth”.

In the year 2000, the second amendment to the LMPA addressed this issue by legislatively acknowledging, for the first time, that essentially healthy childbearing women had, in essence, a right to choose the manner and circumstance of their normal childbirth. This amendment to the LMPA put into black-letter law the relevant theories of “Patients’ Rights” in regard to normal childbirth.

This identifies the lawful right of competent adults to receive relevant information about their health status and any possible, probable or diagnosed medical conditions or complications; after due consideration of these facts, an adult can either consent or decline treatment and other medical services or negotiate a compromise arrangement. This human right is not negated simply because of one’s female gender and pregnant condition, even if an obstetrician sincerely believes that he or she knows better than you what is best for you.

As referred to earlier, Gabee’s “Obstetrics: Normal and Problem Pregnancies” (2nd edition), chapter 42 on the “Legal and Ethical issues in Perinatology” defines “consent” in relation to healthcare as:

“A fundamental premise of Anglo-American law … that no one can touch or treat a competent adult without the adult’s informed consent.” p. 1342.


 

Relevant Excerpts of AGOG’s Ethics’ Committee Opinions:

ACOG’s Committee Opinion #166 on “Informed Refusal” notes that:

“Almost universally, informed consent laws have been liberalized … from the relatively paternalistic “professional or reasonable physician” standard to the “materiality of patient viewpoint” standard.

In the “patient viewpoint” standard, a physician must disclose … the risks and benefits that a reasonable person in the patient’s position would want to know in order to a make an “informed” decision.”

ACOG Opinion #214 on “Patient Autonomy: The Maternal-Fetal Relationship states that:

  • … medical knowledge has limitations and medical judgment is fallibleExisting methods for detection … are not always reliable indicators of poor outcome, and there is often insufficient evidence for risk-determination or risk-benefit evaluation

 

  • The role of the obstetrician should be one of an informed educator and counselor, weighing risks and benefits ….and realizing that tests, judgment and decisions are all fallible.

 

  • Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.

 

  • In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes regardless of the consequences.

ACOG Committee Opinion #214 also identifies serious negative consequences when a patient’s autonomy is violated, stating that:

  • A woman is wronged and may be harmed, whether physically, psychologically or spiritually.

 

  • The patient’s subsequent loss of trust in the healthcare system may reduce the health care provider’s ability to help her and may deter others from seeking care.

 

  • There may be other social costs associated with this violation of individual liberty.

Senator Liz Figeroa, author of the first 3 amendments to the LMPA ~SB 1479 (2000), SB 1950 (2002, and SB 1638 (2006),


SB 1479
 included a “Legislative Intent” section that acknowledged, as a matter of California state law, that childbirth was a normal aspect of biology and not a medical disease. It also identified physiological management — the supportive, non-interventive practices that are a fundamental aspect of community-based midwifery as a non-allopathic discipline that is clearly distinct from obstetrical medicine.

According to the California Legislature,
the midwifery model of care 
includes:

  • informed choice
  • continuity of individualized care
  • sensitivity to the emotional and spiritual aspects of childbearing
  • monitoring the mother throughout the childbearing cycle including
    her physical, psychological, and social well-being
  • providing individualized education, counseling, and prenatal care
  • continuous hands-on assistance during labor and delivery
  • postpartum support
  • minimizing technological interventions
  • identifying and referring women who require obstetrical attention

 

AB 1308 ~ Deletions and Additions to the LMPA
as they affect the California Licensed Midwife’s scope of practice and Standard of Care for Midwives

( Note – the excerpt below is just a section in a 14-page document; there are many other, usually small deletions and additions throughout the Standard of Care/Practice Guidelines as posted on the MBC’s website)

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In 2013, the original “Standard of Care of California Licensed Midwives” (SCCLM) was repealed by AB 1308, including Section V.

In December of 2013, the Medical Board of California (MBC) formally deleted the SCCLM from the Board’s website, because AB 1308 was to take effect on the 1st of January 2014.

However, at the December 5th meeting of Medical Board’s Midwifery Advisory Council, its members unanimously requested that the Medical Board make an unofficial version of the SCCLM available on the Board’s website as a helpful reference for California LMs.

The MBC agreed to develop an informal version that was to be known as “Practice Guidelines”. These new ‘Guidelines’ reflected the many deletions and additions in AB 1308, including drastically altering the Responsibilities of the Licensed Midwife and deleting in toto the Client’s Right of Self-determination (gone like the wind!)

A senior member of the MBC staff (Curt Worden) explained to the Advisory Council and members of the public that the informal ‘Guidelines’ did not have any statutory authority, and therefore would not have any legal standing. This meant the principles it described and its recommendations of “best practices” for community-based midwifery can no longer be used to defend a midwife’s practice in a disciplinary hearing or other legal situations.

–>KEY to legislative changes in the wording in the Standard of Care/Practice Guidelines as it was crafted by MBC staff at Dec 5th, 2013 Midwifery Council meeting

A strike-thru identifies mandatory deletions in the original (SCCLM) document by the MBC’s staff in their effort to be sure the new  “Practice Guidelines” were in compliance with AB 1308

RED = additional restrictions based on AB 1308.

 


     MEDICAL BOARD OF CALIFORNIA

     May 2014

    PRACTICE GUIDELINES
FOR CALIFORNIA LICENSED MIDWIVES

    @@@@

V. RISK FACTORS IDENTIFIED DURING THE INITIAL INTERVIEW OR ARISING DURING THE COURSE OF CARE

DELETED VERSION, replaced by AB1308 –> Responsibility of the Licensed Midwife

With respect to the care of a client with a significant risk factor as identified by the client selection criteria in section IV, other science-based parameters or physical examination, the licensed midwife shall recommend that her situation be evaluated by a licensed physician who has current training and practice in obstetrics.

DELETED, no replacement by AB 1308 –> Client’s Rights to Self-Determination

In recognition of the client’s right to refuse that recommendation, as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal.

If the licensed midwife appropriately documents the informed refusal in the client’s midwifery records, the licensed midwife may continue to provide midwifery care to the client consistent with evidence-based care as identified in this document and the scientific literature.

Post-AB 1308 VERSION of the: “Responsibility of the Licensed Midwife”

With respect to the care of a client who deviates from a normal pregnancy as identified by the client selection criteria in section IV or other science-based parameters, the licensed midwife informs the client that her situation must be evaluated by a licensed physician who has current training and practice in obstetrics and gynecology.

If the physician determines that the client’s condition or concern has been resolved such that the risk factors presented by a woman’s disease or condition are not likely to significantly affect the course of pregnancy, the licensed midwife can continue to provide primary care.

The client should further be informed that unresolved significant risk factors will limit the scope of the midwife’s care to concurrent care with a physician, regardless of whether the woman has consented to care or refused care by a physician. {!!!}

It is recognized that the client has the right to refuse the recommended referral; however, pursuant to the law, the licensed midwife cannot continue care. {!!!}

The licensed midwife will document refusal of the referral in the client’s record. (bold emphasis added)


Faith’s COMMENTARY:

In a side-by-side comparison, this material speaks for itself — AB 1308 is illogicalpaternalistic and profoundly unconstitutional. AB 1308 is out of integrity with ACOG’s own practice standards and ethics, as Committee Opinions # 166 and #214 attest to in the clearest terms.

AB 1308 throws the rights of childbearing under the bus, an act ACOG itself acknowledges in Opinion #214 “,  as a “violation of individual liberty”.

 

AB 1308 was negotiated by lobbyists for the surgical specialty of obstetrics and gynecology. The product of those negotiations is an unconstitutional double standard by the ‘special interests’ of organized medicine and it’s political machine that continues to specifically violate the individual liberty of healthy childbearing families while acknowledging the concepts of ‘informed consent’ and ‘individual liberty’ in relation to women who choose their own obstetrical services.

Could this “disguised restriction” on the services of midwives (generally illegal under NAFTA) also be a restraint of trade that is part and parcel of an organized campaign to eliminate, or at least disadvantage, a class of economic competitors?

I believe these quotes are more than enough to establish the validity of these observations:

*ACOG* Opinion #166 — “Almost universally, informed consent laws have been liberalized … from the relatively paternalistic “professional or reasonable physician” standard to the “materiality of patient viewpoint” standard.”

AB 1308 is specifically paternalist as defined by their very own words.


*ACOG* Opinion #166 — In the “patient viewpoint” standard, a physician must disclose … the risks and benefits that a reasonable person in the patient’s position would want to know in order to a make an “informed” decision.”

AB 1308 says in black-letter law that childbearing women who choose to receive their maternity care from a Ca LM do not have the right of “informed consent”, which also would include the right to decline unwanted obstetrical consultations without losing access to the safety net of professional midwifery care.


*ACOG* Opinion #214 … medical knowledge has limitations and medical judgment is fallibleExisting methods for detection … are not always reliable indicators of poor outcome, and there is often insufficient evidence for risk-determination or risk-benefit evaluation

AB 1308 does exactly the opposite of ACOG’s own ethical standards.  Instead of admitting that “medical knowledge has limitations and medical judgment is fallible, it claims the obstetrical profession is 100% perfect, 100% of the time, and goes on to translate this irrational concept into black letter law.

AB 1308 boldly (shamelessly!) insists that obstetricians are the only appropriate decision-makers, the only people on Planet Earth that can (and should) legally determine what is “best” for childbearing women — especially those who are so foolish as choosing the care of a licensed midwife instead of an obstetrician and furthermore, are planning an OOH birth.


*ACOG* The role of the obstetrician should be one of an informed educator and counselor, weighing risks and benefits ….and realizing that tests, judgment and decisions are all fallible.

Bingo — everything discussed above, plus the idea that members of the obstetrical profession (a) don’t really like the role of informed educator and counselor — takes too much time and there is no billing code for is, so its a money loser, and (b) obstetricians (at least those who belong to ACOG) think obstetrical medicine is infallible, and that any test, judgment, or decision made by an obstetrician is likewise infallible


*ACOG* Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.

I admit to being particularly nutty about this one. ACOG Opinion #214freely  acknowledges that: “Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances” then it turns around and sponsors AB 1308, which says in plain English:

  • the midwife must inform the client that her situation must be evaluated by a licensed physician who has current training and practice in obstetrics and gynecology.

 

  • … informed that unresolved risk factors will limit the scope of the midwife’s care to concurrent care with a physician, regardless of whether the woman has consented to care or refused care by a physician.

 

  • It is recognized that the client has the right to refuse the recommended referral; however, pursuant to the law, the licensed midwife cannot continue care.

In the context of AB 1308, ACOG’s ethical statements leave me speechless!


*ACOG* Opinion #214 also identifies serious negative consequences when a patient’s autonomy is violated, stating that:

A woman is wronged and may be harmed, whether physically, psychologically or spiritually.

The patient’s subsequent loss of trust in the healthcare system may reduce the health care provider’s ability to help her and may deter others from seeking care.

There may be other social costs associated with this violation of individual liberty.

I can only say “duh!”, since this is so self-evident.

Gabee’s Obstetrics’s comments on “Forced Cesareans” on page 1336-37, put the icing on this cake by saying:

“Obstetricians should refrain from performing procedures** that are unwanted by a pregnant woman. … inappropriate reliance on judicial authority may lead to undesirable social consequences, such as the criminalization of non-compliance with medical recommendations.

{** (this would include mandatory ‘evaluations’ by an OB and putting women into the position of having to choose between highly medicalized hospital services and either a lay-midwife attended or an unattended labor and birth)

In 1990, The District of Columbia Court of Appeals, in a strongly worded opinion, essentially adopted the ACOG as law, holding the decision of pregnant women must be honored in all but:

extremely rare and truly exceptional circumstances“.  (emphasis added)

How the limitations imposed by AB 1308 affect the LMPA and its previous amendments

Unfortunately, the unjustified and unconstitutional AB 1308’s assault on mothers and midwives does not stop with the egregious violation by ACOG of its own ethical guidelines but violates the principles established in the LMPA itself.

AB 1308 has turned the ‘shield’ provided by the LMPA into a ‘sword’ to be wielded by organized medicine against the best interests of women as clearly established in SB 350 and SB 1479.

The purpose and Legislative Intent of the LMPA of 1993 (SB 350 by Senator Killea) and the 2000 amendment (SB 1470 by Senator Figuera) was to provide healthy childbearing families with access to access to high-quality, affordable and acceptable (as defined by the family) maternity care.

It was my honor to personally know and converse with Senator Lucy Killea a number of times during the long effort to pass a non-nurse midwifery licensing law. Senator Killea was passionate about the need for a modern, non-nurse (and not-medically dominated) licensing system for the direct-entry practice of traditional midwifery.

In particular, Senator Killea saw this as reducing the human tragedy and preventable expense to the MediCal program caused by the high rate of premature birth often associated with the inability of low-income families to find affordable and acceptable maternity care.

California Senator Lucy Killea, author of the Licensed Midwifery Practice Act of 1993 and our heroine!

Senator Killea was equally committed to creating a rational and legal option for ‘alternative’ (i.e. traditional!) care so childbearing families would be able to receive childbirth services from professionally-trained and state-regulated licensed midwives. This would eliminate, or at least greatly reduce, the number (and associated dangers) of unattended birth.

Senator Killea passed that Olympic torch on to Senator Figueroa. SB 1479 forever eliminated the spurious idea put forth in the 1976 Bowland Decision that healthy childbearing women in California did NOT have the right to control the “manner and circumstance” of normal childbirth.

Thanks to Senator Figueroa — a talented and tireless advocate for mothers and midwives — the definitions of midwifery originally proposed by a national consumer group (Citizens for Midwifery), which identified normal childbirth as a non-medical event, allowed the legal definition of childbirth as a ‘normal’ biological function (and not a medical-surgical one) to be incorporated into California Law.

Negating the Bowland Decision is more important than many of us can imagine, as the midwives criminally prosecuted in the Bowland case were charged with violating section 2052 of the B&P Code, which is the illegal practice of medicine. This statutory language prohibits practicing or holding oneself out to practice “any system or mode of treating the sick or afflicted in this state“.

Kate Bowland, Linda Bennet, and a third midwife were arrested for offering to support a normal biological process in healthy childbearing women, but they were criminally prosecuted for “treating the sick or afflicted“. In other words,  when midwives “hold themselves out” to be midwives, they are arrested for pretending to be doctors, and/or for doing something (in this case, attending a normal birth) that only MDs are legally authorized to do.

This crazy and factually inaccurate definition made the practice of non-medical midwifery a ‘crime‘ in 1973, when the Santa Cruz Women’s Health Clinic was raided and shut down, and its midwives (one of who was herself many months pregnant) carted off to jail in the middle of the night.

SB 1479 ended that archaic and illogical definition that equates tradition, non-medical midwifery to an illegal practice of medicine.  Midwives still “treat” women — that is, we treat them with compassion and respect, which is not an illegal practice of anything!

For decades to come, Senator Figueroa can personally take credit for providing all the citizens of Calfornia with this wonderful description of  “The midwifery model of care”.

According to the SB 1479, professional midwifery care by California licensed midwives includes:

  • informed choice
  • continuity of individualized care
  • sensitivity to the emotional and spiritual aspects of childbearing
  • monitoring the mother throughout the childbearing cycle including
    her physical, psychological, and social well-being
  • providing individualized education, counseling, and prenatal care
  • continuous hands-on assistance during labor and delivery
  • postpartum support
  • minimizing technological interventions
  • identifying and referring women who require obstetrical attention

Pssst! Pass this good news on to everyone who will listen ~ https://tinyurl.com/ydcmxlkv

~ Happy Birth Day ~

Photo Taken by Rosanna Davis, LM

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https://tinyurl.com/ybvde6cxThis URL links to Parts 1. You can access Part 2 by clicking the link at the bottom of Part 1. 


The story behind the 1993 Licensed Midwifery Practice Act and organized medicine’s 2013 amendment to the LMPA that irrationally restricts access to care by Ca LMs

The California Licensed Midwifery Practice Act was introduced in 1993 by Senator Lucy Killea specifically to reduce the risks that pregnant women and their unborn/newborn babies face when the mother-to-be does not receive quality maternity care and the associated complications of “no care” which includes an increase in premature births, undetected pregnancy complications for either mother or unborn baby, and the dangers of unattended births.

Whether planned or unplanned, not having prenatal care and not having a trusted and skilled birth attendant present during labor and birth drastically increases the danger to mothers and babies both.

Lack of prenatal care is associated with a dramatic increase in the rate of prematurity. Hospital caring for premature babies can be as much as a million dollars per infant and often includes expensive long-term disabilities. Treatment of newborns with respiratory-related difficulties, which is a major problem for premies, is the *very most expensive* type of hospital care — even more frequent and expensive than treating spinal cord injuries and 3rd-degree burns.

More than half of the hospital expense for pre-term babies is billed to the State’s MediCal program. Under dire circumstances, even high-income families come to depend on this state-federal program to pay for neonatal intensive care when the parents’ private insurance maxes out. Unfortunately, the problems associated with a premature birth do not end when the baby is discharged from the hospital. While the negative effects of pre-term birth fall heaviest on parents and child, there are also expensive downstream problems for our schools and other hidden or long-term costs to society.

As for the risks of unattended birth, they are obvious and also expensive, both in treasure and human tragedy.

The Legislative Intent of SB 350 was to mitigate these problems by better serving the needs of families who couldn’t find afford conventional maternity care and/or wanted to avoid the highly medicalized and interventive hospital care that is the current standard in the US. These families were seeking a reasonable, safe and lawful alternatives, including care by midwives trained to support the physiology of normal childbirth in a non-medical setting — the family’s home or free-standing birth centers staffed by professional midwives and family practice physicians.

Why Nurse-Midwifery Was/Is Not an Answer

Certified Nurse-Midwife, Kate Bowland (standing) & provider of planned home birth services in Santa Cruz County for 45 years (Yea Kate!)

Prior to passage of the LMPA in 1993, California law only legally recognized the practice of certified nurse-midwives (the Nurse-Midwifery Act of 1974). However, each CNM is only permitted to provide midwifery services if an obstetrician is willing to enter into a written contract with her to legally “supervise” them.

Unfortunately, the 1974 nurse-midwifery licensing law does not require that any California-licensed obstetrician actually supervise a nurse-midwife.

As an additional disincentive to the practice of nurse-midwifery, the legal supervisory role of obstetricians means doctors can be held liable for care provided by the nurse-midwife if there is a malpractice suit. Obviously, their professional liability insurance carriers do not allow them to do this.

The obstetrical profession has always seen midwifery as a competing profession and economic threat. So it’s no surprise that 99.99% of California obstetricians refuse to take on the onerous responsibility for one of their competitors. With rarest of exceptions, the few who do agree to supervise a nurse midwife insisted that she only attend hospital births, which required the midwife to abide by obstetrical department protocols  (instead of physiologically-based practices).

Standard obstetrical protocols for hospital delivery, with the mother lying on her back on a delivery room table, buried under sterile drapes in an anti-gravitational position while trying to push her baby uphill while her obstetrician, L&D and nursery nurses, several medical students and other hospital personnel look on.

In 1976, families who were hoping to receive community-based midwifery care from a state-licensed CNM were dismayed to discover that the new law was obviously unworkable and did not allow this so these frustrated families sought out the services of lay midwives. However, if they were unable to locate a suitable birth attendant in their geographical area, they often opted for an unattended birth. This was such an obviously dangerous problem that Jerry Brown, during his first term as governor (1975-83), became personally involved in supporting a new, non-nurse midwifery licensing law.

Gov. Brown 1975

Governor Brown’s administration described the impasse over mandatory supervision of midwives by obstetricians as “structural barriers to practice” inserted by organized medicine into the 1974 nurse midwifery bill. This prevented nurse-midwives from providing services to low-income women and families seeking alternative care, which was the major purpose of the licensing law. The nurse-midwifery law was also supposed to greatly reduce the cost of maternity care being paid by the State’s MediCal program, but the unworkable physician supervision clause rendered that useless as well.

In 1976, Gov. Brown directed the California Department of Consumer Affairs (the DCA is a state agency under the control of the executive branch) to actively support passage of a new, non-nurse midwifery-licensing law [AB 1896] as an independent discipline that was not under the control of the medical profession (which unfortunately is still the case for California nurse-midwives 54 years later).

During this period of time, three midwifery licensing bills (AB 1896, AB??, SB??)  were introduced and promoted by the Governor Brown’s office and Mr. Michael Krisman, Deputy Director of the Department of Consumer Affairs**.

Unfortunately, the lobbying efforts of organized medicine were able to overrule even the direct support of Governor Brown and the DCA. Altogether, there were six attempts to pass a non-nurse (direct-entry) midwifery licensing law between 1976 and 1993 failed.


{** See the Department of Consumer Affairs’ 11-page document written by Deputy Michael Krisman September 8, 1977 entitled AB 1896  –  BACKGROUND INFORMATION PAPER ~ THE MIDWIFERY PRACTICE ACT OF 1978

DCA’s pro-active support of a new mfry licensing law included creating the original  “Midwifery Advisory Council” in 1981. Lay midwives (including myself) and many grassroot activists met regularly in the Capitol building in a conference room provided by the DCA to work on midwifery legislation that would allow state-licensed nurse AND non-nurse midwives (as a combined legal category) to be reimbured by MediCal when providing care to eligible low-income families. 

In 1981 & 1983 public hearing were held in northern and southern parts of the State. These Alternative Birth Hearings were chaired by State Senator John Vasconcellos and Mr. Jack Winters (Editor’s note-2-self: Janet Ashford to may remember names & other details and still have newspaper clippings).


Senator Lucy ~ Author of the LMPA and Heroine to the State’s childbearing families and direct-entry midwives 

We are sad to report that Senator Killea died January 18th, 2017. She is remembered and missed!

When the overwhelming odds against passage of a non-nurse midwifery law are taken into account, Senator Lucy Killea’s offer to author and vigorously, personally promote SB 350 can be seen as the brave and bold move it really was. Senator Killea was a remarkable woman with an extraordinary history of public service.

During WWII she was employed by the US military in Europe as an “operative” (i.e. a spy). At the end of WWII, she and her new husband Jack Killea were the second and third people hired by then-President Harry Truman to run the newly authorized Central Intelligence Agency (CIA).

Senator Killea was also the only member of the Legislature to be denied communion by the Catholic Bishop of her San Deigo parish church in retaliation for her vote to decriminalize abortion.  So her effort to find an alternative solution to the problems created by the historical domination of all childbirth services in the State by organized medicine over a period of 54 years was in line with her illustrative record of personal courage and ethical standards translated into protective public policy.

The intent of SB 350 was to professionalize non-nurse midwifery and ultimately improve maternal-infant outcomes in California. The ancillary goal of the LMPA was to reduce the State’s share of expense thru the MediCal program that was associated with a high rate of prematurity and childbirth-related complications resulting from a lack of access to maternity care and unattended births.

The LMPA passed the California Legislature unanimously and was signed into law by the governor on October 11, 1993. In 2016, there were more than 400 midwives licensed in California under the LMPA and over 3,000 babies born in non-medical settings (birth centers and family residence) under their care.  **Licensed Midwives Annual Report (LMAR-2016)

SB 1479 ~ An Important & Clarifying Amendment to the LMPA by Senator Liz Figueroa

California State Senator, 2000-2006

The LMPA was first amended in the year 2000 by Senator Liz Figueroa. SB 1479 stated as a matter of California state law that childbirth was a normal aspect of biology and not a medical disease. SB 1479 legally clarified the characteristics of physiological management and the supportive, non-interventive practices associated with the community-based practice of midwifery, which is a non-medical (in the sense of non-allopathic) discipline legally distinct from the allopathic practice of obstetrics.

By California law, the licensed midwifery model of care includes:

  • Informed choice
  • Continuity of individualized care
  • Sensitivity to the emotional and spiritual aspects of childbearing
  • Monitoring the mother throughout the childbearing cycle including
    her physical, psychological, and social well-being
  • Providing individualized education, counseling, and prenatal care
  • Continuous hands-on assistance during labor and delivery
  • Postpartum support
  • Minimizing technological interventions
  • Identifying and referring women who require obstetrical attention

Hour-old baby boy in a “bunny bag” — a midwife’s invention that is a tiny sleeping bag made from cloth diapers and super absorbent microfiber fabric. It helps keep newborns warm while being held by family members, who often have a hard time keeping the baby covered and warm

In the year 2000, this amendment to the LMPA formally acknowledged the right of essentially healthy pregnant women to exercise self-determination in regard to normal childbirth. This was an affirmative response by the Legislature to a legal issue raised by California Supreme Court in the Bowland Decision.

In 1976 the Bowland Court ruled that childbearing women had no intrinsic right to make decisions about the type of care they received during pregnancy and childbirth, noting that the California Legislature had “never gone so far” as to acknowledge that, as a class, healthy childbearing women in California had the right to choose “the manner and circumstances of normal childbirth”.

It should be noted that the Bowland Count did not rule say that childbearing women couldn’t legally decline prenatal care during pregnancy or plan to have an unattended birth. They just noted that the Legislature had never affirmed a pregnant woman’s right to choose a maternity care provider that was OTHER than conventional hospital-based obstetrical providers.

The Legislative Intent of SB 1479 rectified this oversight, acknowledging that in California:

(b) Every woman has a right to choose her birth setting from the full range of safe options available in her community

(e) The midwifery model of care is an important option within comprehensive health care for women and their families and should be a choice made available to all women who are appropriate for and interested in home birth.

This provides legislative authority for the practice of traditional (i.e. non-physician) birth attendants and the choice by parents of tradition/alternative (out-of-hospital) locations.

In 2002, SB 1950 (Figueroa) mandated that a regulation be promulgated that would define a midwifery standard of care for California licensed midwives). This amendment resulted in the approval of the Standard of Care for California Licensed Midwives (SCCLM) by the California Medical Board in September 2005 and its formal adoption the Office of Administrative Law (OAL) in the regulatory code March 6, 2006.

In 2006, SB 1638 (Figuroa) directed the California Medical Board to create a Midwifery Advisory Council composed equally of Ca LMs and consumers. The Council meets 3 or 4 times a year and currently has 6 members. Advisory Council meetings are now webcast for public viewing and those videos are archived for reference at a later time by the public.

SB 1638 also mandated that the MBC develop an administrative process for the annual collections of statistics for all licensed midwives to be reported and collated by OSHPD (Licensed Midwives Annual Report) and formally reported by the Medical Board to the State Legislature each year.

Starting in 2007, the LMAR has tracked the number of families that received care from Ca LMs each year and standard maternal-infant statistical outcomes. These include the number of normal vaginal birth attended in an out-of-hospital setting, number of hospital transfers and all sub-optimal outcomes, including Cesarean deliveries and any serious morbidity within first 6 weeks and mortality. These online annual reports have been available to the public since 2010.

I cannot stress enough that all these changes were sought out by practicing midwives and consumer groups, especially the California Association of Midwives (CAM) and California Families for Access to Midwives (C-FAM).

We all worked hard and spent organizational funds to find a legislator willing to sponsor these amendments. After this critical stage was accomplished, professional and advocacy groups as the office staff of the two Legislator’s offices (special thanks to Liz Smith and Vincent Marchand in Sen. Figueroa’s office 2000-2006) We all burned the midnight oil to push these bill through.

Licensed midwives and consumer groups worked for changes in the LMPA that would mandate annual reporting by each practicing midwife, who would be required to provide a great many details about the care provided, including any bad outcomes. We believed that legislation mandating the Medical Board to host a Midwifery Advisory Counsel would dramatically improve the professional relationship between licensed midwives and our regulatory agency (MBC). Indeed, this has greatly improved relationship btw our regulatory agency and its midwife licentiates.

In an on-going effort to make midwifery the best it can be, the 1993 LMPA and its first 3 amendments allowed the profession of licensed midwifery to further fine-tuning the care it lawfully provides to childbearing families in California seeking alternative childbirth services that are lawful, safe, cost-effective and able to reduce the likelihood that the laboring woman and her newborns would be exposed to risky and unwanted medical and surgical interventions.


 

Senator Lucy Killea, author of SB 350 (LMPA of 1993) as seated member of a legislative hearing

The problem is NOT Senator Killea’s midwifery licensing law, but the continued LACK of access to high-quality maternity care and midwifery services caused by inappropriate amendments to the LMPA sponsored by special interest groups

Whatever people may think of community-based midwifery, they should be reassured by the following facts:

The public health problems surrounding normal childbearing in California are not the result of the care by state-licensed midwives, but the preventable danger to pregnant women and their unborn babies when they don’t get regular prenatal care and are forced to chooe between the Devil and he Deep Blue Sea — eiher an unwanted hospial birth (or in some cases, an unwanted Cesarean) of have an unattended birth and attendant risks

The combination (no prenatal care-unattended labor, birth and neonatal period) has 20 to 40-fold increase in mortality of mothers and unborn/newborn babies. One study of unattended births in a religious group in Indiana identified 6 maternal deaths out of 344 births or 1 mother and 21 stillborn or newborn babies for every 57 births. (Perinatal & maternal mortality in a religious group avoiding obstetric care – Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:  ~ see abstract at end of this document)

 

Preventing Needless Childbirth Tragedies 

The tragedies cited in the study above were all “preventable” deaths due to untreated hemorrhage in new mothers and untreated infection in neonates. Obviously, the basic issue in these cases was a regrettable (and I believe an uninformed) choice made by these families to eschew prenatal care and having a trained birth attendant present during labor and birth, as well as refusing to use medical and emergency services in the face of life-threatening complications.

But these high maternal-infant mortality statistics are a grizzly testament to just how successful midwifery care is at preventing such tragedies.

As attested to by the last 10 years of data collected by the California Licensed Midwives Annual Report (thank you Senator Figeroa!), we know the majority of unexpected problems associated with childbirth can be prevented or successfully managed when professionally-licensed midwives are authorized to:

  • Provide prenatal care with regular risk-screening and referrals to medical services as needed
  • Physically examine and evaluate the health status of the pregnant woman and her unborn fetus prior to the term onset of active labor (late pregnancy, very early labor), so those with complications can be prophylactically transferred to medical services
  • Be present during the mother’s active labor, the birth of her baby and immediate postpartum-neonatal period and the 6-week of follow-up care for both mother and baby, which also includes hospital transfer and/or use of emergency medical services as needed

But starting in 1949, when the original 1917 midwifery licensing law was repealed by the California Legislature at the request of the medical community, no such safeguards were legally available in California until the passage of the LMPA in 1993. During that 44-year gap, California families had only two legally-recognized options:

(a) “no care” – i.e. no prenatal care; unattended birth; delayed access to emergency medical services when needed
(b) medicalized obstetrical care that is often experienced by laboring women and their families as similar to being in intensive care unit (ICU).

If those two extremes — “no care” and highly medicalized, expensive hospital-based obstetrical care for healthy women — met the needs of 100% of childbearing women in California, there would have been no need for the Legislature to ever create the new category of professionally-licensed direct-entry midwifery.

Unfortunately for the special interest groups who supported the status quo between 1917 and 1993, the actual facts belie any assumption these two extremes were able to meet the needs of the childbearing public or the fiscal responsibility of the State’s MediCal program to pay for the maternity care of eligible low-income families.

Midwife hands healthy newborn baby up to its excited new mother moments after its birth.

Compelling evidence in more recent times that a state-sanctioned category of professional non-nurse midwives was necessary is unanimous passage by the California State Legislature of the original Licensed Midwifery Practice Act of 1993 (SB 350) and three (SB 1479, SB 1950, and SB 1638 – Sen. Figueroa) of its four amendments.

As the risk of being redundant, the incontrovertible facts are both plain and simple: The presence of a trained midwife, like that of a lifeguard at the pool, always makes childbirth orders-of-magnitude safer for childbearing women and their unborn and newly born babies.

That means providing the option of professional midwifery care to low-income women, socially and religiously conservative families, ethnic groups that prefer traditional forms of midwifery care, and families that, for a great variety of valid and rational reasons want or need an alternative to highly-medicalized hospital obstetrics. Since 1993, the answer to what otherwise would be insurmountable problems had been the LMPA.

Midwifery Licensing and its Important Contribution to Childbearing Families

California Licensed Midwife Donna Driscoll with one of her new granddaughters.

Passage of the LMPA in 1993 legally acknowledged and preserved the traditional arts of midwifery within the context of modern medical science and evidence-based “best practices”. Through formal education and clinical training, over 400 California licensed midwives have had the opportunity to incorporate the historic quality of traditional midwifery care with the “best practices” of modern medicine.

If a medical problem should occur in an out-of-hospital setting (home or birth center), midwives are scientifically trained first-responders able to provide effective emergency interventions, and refer or transfer mother or baby to medical providers whenever necessary. As noted earlier, this reduces risks during pregnancy, and the frequency and severity of preventable childbirth complications, making normal childbirth in healthy women both *safer* and more cost-effective. 

2013 ~ Hostile taker-over by organized medicine is a disguised restriction on midwifery services and denial-of-service to healthy childbearing women   

Unfortunately, the fourth amendment to the LMAP  represents a ‘hostile take-over’ — AB 1308  was sponsored by lobbyists representing organized medicine in 2013. This amendment, which was negotiated by lobbyists for ACOG, drastically reduced the scope of practice for direct-entry midwives and the number of essentially healthy childbearing women that California licensed midwives can legally provide services to.

Prior to its passage, the LMPA the scope of practice for CaLM was defined as providing routine prenatal care, risk-screening, and normal childbirth services to women with no evident medical, obstetrical or perinatal complications. Only if a pregnant or laboring woman or newborn developed a clinically significant complication did the LMPA mandate obstetrical care or transfer to hospital-based services. This logical and common sense provision of the law was fully supported by parents, midwives, the medical profession and the general public as an appropriate safety measure. Unfortunately, AB 1308 changed that for the worse.

AB 1308 also directly repealed the California Licensed Midwives Standard of Care and specifically negated our Standard of Care’s policy statement on the licensed midwife’s ethical duty to inform and recommend physician consultation in relation to all identified risk factors, and simultaneously denied the childbearing woman’s right to self-determination (i.e. Patients Rights), including the right to decline obstetrical referrals and evaluations in relation to certain risk factors.

AB 1308 eliminated the childbearing family’s right of self-determination and informed consent/refusal, while dramatically increasing the number of childbearing families that now don’t “quality” for midwifery services under the LMPA.

I believe this provision is unconstitutional under both state and federal law.

The legal theory of ‘Adherence’ ~ a shield for midwives and mothers

AB1308 this violates a legal theory described as “adherence“. This describes a logical expectation that a law or set of laws relating to the same general theme has an internal integrity. New laws or novel interpretations of provisions in an existing law that violates that integrity risk being struck down by the Courts.  For example, if a law developed to protect minor children is being implemented in ways that predictably increased the level of danger experienced by minor children, those actions would be found to violate the basic intention of the law based on the theory of “Adherence’.

The legislative intent and provisions of the LMPA and three of its four amendments all materially enhance a midwifery licensing law whose purpose is identified in the “Legislative Intent” as making childbirth safer. The LMPA was to design to achieve these goals by creating a legally-defined mechanism to professionally train and license non-nurse/direct-entry midwives. This was to make state-regulated midwives generally available to families that couldn’t afford (n0 health insurance), couldn’t find (due to geographical reasons) or didn’t believe conventional obstetrical care acceptable (due to religious, ethnic traditions, or PTSD).

All these aspects and implementation serve the intention of the LMPA to make pregnancy and childbirth safer for California families by providing prenatal care, risk screening, referral to medical services as indicated and reducing the risk to mothers and their unborn/newborn babies by eliminating unplanned home births because midwifery care was not available.

Mandatory Obstetrical Consultation and Evaluation under AB 1308

This amendment to the LMPA now requires mandatory obstetrical consultation for possible risk factors, even if this goes directly against the wishes of the childbearing woman and her family. The category of “risks” describes the possibility of a complication in the future but is not itself a present complication that requires any treatment.

The historical and contemporary standard of care as provided by midwives and other maternity care professionals has always required that parents be immediately informed about the presence and nature of any identified risk. When the risk is clinically significant, non-MD practitioners routinely recommend consultation with an appropriate medical specialist. However, parents have a legal right to decline and after carefully pondering the issue, some do. Consultation is not mandatory unless something is really unusual or abnormal and the practitioner believes it would be unethical to continue care without additional information.

Unfortunately, AB 1308 turns all this on its head. It mandates obstetrical evaluation, even when the moter-to-be objects or decline or the health issue involved would more appropriately be referred to another medical specialty (such as an endocrinologist or perinatologist).

Nonetheless, the law stipulates that the pregnant women be seen and evaluated by “a physician with training in obstetrics” before her midwife can provide additional care. Should the childbearing woman be so bold as to exercises her legally-recognized Patients’ Right to refuse any such recommendation, no Californa licensed midwife will legally be able to provide her with additional prenatal care or childbirth services.

If the client agrees to be evaluated by an obstetrician, and can both afford and find an OB in her geographical area who is willing to consult with her, this doctor has a legal duty to the mother under AB 1308 with determining if its appropriate (i.e. in his opinion safe) for the pregnant woman to have a midwife-attend OOH birth in light of the identified risk factor.  Of course, this entails enormous legal liability for the obstetrician and so like the issue of obstetricians, the choice that obviously favors the obstetricians is to just refuse to see women referred by midwives.

When obstetricians do evaluate these patients, many routinely recommend against additional midwifery care, thus shielding themselves from all potential legal entanglements. Others OBs agree to examine the woman, but won’t write anything in the medical record, lest they be sued later on. However, without documentable approval by an obstetrician, it’s illegal for the client’s midwife (or any other Ca LM) to provide childbirth services to her.

The consequences of this provision of the LMPA are extremely problematic for all involved (including obstetricians). Under the affects of AB 1308, a significant number of essentially healthy women are needlessly forced into what they believe is an unnecessary (and unwanted) hospitalization and highly-medicalized childbirth under obstetrical protocols.

 

The adjacent photo is from a mother was who was still upset and angry more than a year later about unnecessary intervention in her birth and iatrogenic complications for herself and her baby.  She sent this picture of her newborn in the hospital’s NICU to her obstetrician and the L&D nurses, expressing her anger and disappointment.

The original caption is to small to read, but it says:

Our son spent 3 days like this and couldn’t use his right hand for a year because of an unnecessary induction and my being told not to push for 30 minutes becasue it was shift change. I also have a debilitating bladder condition caused by not being “allowed” to push.

In the wake of AB 1308 restriction, a small but still substantial number of these women had such a bad experience with a previous hospital birth that elective hospital birth is out of the question for them. If their local midwives aren’t legally allowed to provide care to them due to restriction introduced by AB 1308, they will look for a lay birth attendant (thus re-inventing unlicensed lay midwifery!) or plan to have an unattended birth.

Up with this we cannot and should not put!

The only appropriate changes to the LMPA are ones that improve access by childbearing families or better meet their needs. while also improving the quality of professional midwifery practice. All future amendments to the LMPA must be sponsored and/or supported by consumer organization such a California Families for Access to Midwifery (C-FAM)  and state midwifery organization such as the California Association of Licensed Midwives (CALM) and California College of Midwives (CCM).

All these parameters applied to  SB 350 (LMPA) the 1st three amendments (SB 1479, SB 1950, & SB 1638) introduced in 2002, 2002 and 2006. But unfortunately, this was not the case for the amendment introduced in 2013.

AB 1308 directly negated many of the most important the contributions of Licensed Midwifery Practice Act, and the safeguards it provided to childbearing families by making it possible for a trained, experienced and equipped midwife to be present, and in most instances, able to prevent or successfully manage the unexpected problems associated with childbirth, especially as this applies to giving birth in out-of-hospital settings.

This must be fixed and soon.

 


Midwives and must consumers be (or become) informed about the history of non-nurse midwifery licensing in the State so we can explain it to others and make a compelling case to members of the State legislature.

First, we have to tell our story in order to find an author willing to carry a bill, and then we have to convince a sufficient number of legislators to support our efforts. This is especially critical for the seven Legislators who sit on the Business and Professions Committees of both chambers, a who can so easily kill a bill long before a floor vote.

To better understand the reasons why AB 1308 is not just bad policy for Ca LMs, but also unconstitutional from the perspective of childbearing families, please continue reading:

Part 3 — Comparison of ACOG Opinions #166 & #214 + SB 1479 w/ Post-AB1308 Medical Board “Practice Guidelines” in 2014

 

Associated Topic –> The Obstetrical Standard of Care in the US – Historically Illogical, Fundamentally & Fatally-flawed


Reference #1:

Perinatal & maternal mortality in a religious group avoiding obstetric care – Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:

This control group consists of women with the same general health and demographic characteristics that are seen in the CDC birth registration data. This is predominately healthy, white, middle-class women who had economic access to all categories of maternity care providers and settings, but in this case, purposefully choose unattended births.

Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that rejected all forms of medical care under all circumstances – no prior diagnosis or treatment of chronic medical problems, no risk-screening of mothers during pregnancy, no prenatal care, no trained attendant during childbirth and no emergency transfer of mother or baby with life-threatening complications to a medical facility – a situation similar to rural parts of the developing world.

Out of 344 births, the unattended group had 6 maternal deaths and 21 perinatal losses. The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live births (92 times higher than Indiana’s MMR for the same period) and one perinatal loss for every 16 births or PNM rate of approximately 45 per 1,000.

 

tinyurl.com/ybvde6cx

California Licensed Midwife Alison Price

Safe, cost-effective Childbirth in the 21st Century

Healthy childbearing women and their babies are always safer when the mother-to-be receives regular prenatal care during pregnancy, is cared for by a trained and experienced birth attendant throughout active labor, the birth of her baby, the immediate postpartum-neonatal period and initial breastfeeding and that both new mother and new baby receive appropriate follow-up care for at least six weeks after the birth.

That’s exactly what California Licenced Midwives are trained, licensed, equipped to do.

The California Licensed Midwifery Practice Act of 1993 (LMPA)

Family w/ four midwife-attended births, 1st one in the hospital, and the next three as planned home births, dad caught baby #4 (a girl) just as the midwife was arriving. See dad’s big grin holding his new daughter!) ^O^

The Licensed Midwifery Practice Act was passed unanimously by the California Legislature in 1993. Since then, approximately 50,000 families in California have had a professional midwife-attended spontaneous vaginal birth in out-of-hospital locations.

Every year more than 4,000 healthy pregnant women in our State seek alternative forms of maternity care from licensed midwives. In 2016, more than 3,000 babies were born in a non-medical setting (birth centers and family residence) under the care of California Licensed Midwives.

The best description of the role of professional midwives is to characterize them as “educated observers with emergency response capacity“. We watch, look and listen for a living, sitting quietly on the sidelines but always ready and able to spring into action, if or when the need arises.

Complications, while infrequent, can occur in any pregnancy or labor, no matter how healthy the mother or normal the pregnancy. For this reason, professional midwifery care always includes timely access to and appropriate use of medical services as an integral part of physiologically-based midwifery care, to be called on when needed to treat complications or if requested by the mother.

Should an unexpected medical problem occur during pregnancy or childbirth, midwives are trained as first-responders, able to provide effective emergency interventions, and when necessary, refer or transfer, or arrange rapid transport of mother or baby to appropriate medical services.

This greatly reduces risks during pregnancy, and the frequency and severity of preventable childbirth complications, making normal childbirth in healthy women both safer and more cost-effective. Midwives also provide emotional and social support for new parents in the months preceding and following the birth. 

For women who received maternity cared from Ca LMs between 2007 and 2016, the incidence of prematurity was under 2**. In the U.S. as a whole, preterm and premature births occur in about 12% of pregnancies and this is one of the top causes of infant death in this country.

For women who gave birth under the care of Ca LMs during those same years, the incidence of Cesarean delivery is less than 10%**, while the US rate is 32% — a three-fold higher rate that is associated with increased infant morbidity and maternal mortality.

**Licensed Midwives Annual Report (LMAR-2007-2016).

Since 49% of the cost for all hospital births in California are reimbursed by the state-federal MediCal program, much lower rates of prematurity and surgical delivery associated with the professional services of licensed midwives save taxpayers many millions of dollars every year.

 



Why most Families Choose Out-of-Hospital Birth
 

The reasons women frequently give for choosing an OOH location for normal childbirth are:

  • cultural traditions 
  • strongly-held religious beliefs
  • economic issues
  • personal preference 

These reasons are relatively self-explanatory, so I won’t belabor the point. However, there are other important, but not well-known or understood reasons that I’d like to explain in some detail.

Childbirth in Women with PTSD


When midwives ask potential clients why they are interested in community-based midwifery care, a significant number of women say their reason for choosing OOH birth is in reaction to a prior traumatic experience. Women who experienced childhood 
physical or sexual abuse, or were the victim of a violent crime or sexual assault as adults (including “date-rape”), are naturally distrustful, even fearful, and often develop a very rational fear of being overpowered.

As a result, these women live with a pervasive level 
of anxiety about their ability to protect their bodily integrity. They purposefully avoid situations that entail disparities in social status or power between themselves and other ‘powerful’ individuals or groups. They also avoid intimidating situations, such as being required to lay on their backs in physically vulnerable positions, which is a necessary aspect of gynecological exams and other invasive medical procedures. These and similar incidents often trigger symptoms of PTSD including flash-backs and disassociating from their emotions or surroundings.

Normal birth in a hospital with staff standing by and several medical students observing

A small proportion of women with this debilitating form of PTSD either avoid pregnancy altogether or schedule an elective Cesarean. It’s the woman’s way of circumventing what she sees as the indignity of invasive vaginal exams during labor and other medical procedures. Hospital protocols being what they are, she doesn’t believe that her physical and emotional privacy will be adequately protected. Scheduling a surgical delivery also eliminates her fear of a loss of control and bodily integrity during a normal vaginal birth in an environment that she often sees as quasi-public venue.


Fortunately, the majority of previously traumatized women are able to tolerate and even welcome pregnancy. A significant proportion these brave souls cope with their ‘special circumstance’ (PTSD) by seeking out community-based midwifery care. A
ssuming the mother remains healthy, the pregnancy is normal, and her labor progresses normally, these women plan to have a midwife-attended home birth or to give birth in free-standing birth center staffed by midwives and, in some places, family practice physicians.

The Intimidating Aspects of Hospitals and Hospitalization

The second most frequent traumatic experience that childbearing women discuss when asked why they are interested in community-based midwifery is a difficult personal experience with hospitalization

Such women often describe a traumatic experience as a child with an 
illness or injury that required them to be hospitalized and abruptly separated from their family for weeks or months. Their care many have included isolation due to a serious infection, or 2nd and 3rd-degree burns with painful or distressing treatments. Sometimes the traumatic hospital experience happened as an adult and involved a serious accident of a family member or the prolonged hospitalization of an elderly or terminally-ill relative. 

For the lay public (which is 99% of us), hospitals are intrinsically intimidating
 places. Doctors often hold our lives or those of our loved ones in their hands, but frankly, they are also busy ‘important’ people who can be brisk and off-putting.

Historically, the authoritarian nature of the medical culture always made the doctor/not-a-doctor relationship intrinsically intimidating. While its much better today than a hundred years ago, the universally perceived power-disparity between medical doctors and the rest of us is still operative. We are afraid of ‘wasting the doctor’s time’ or making a fool of ourselves, which interferes with our ability to ask important questions or to risk taking up the doctor’s time to fully discuss treatment options.

F
or hospital patients, these factors represent a double whammy. To be a patient is to also be in pain, afraid, sick as a dog, intimidated by high-tech medical equipment, and laying nearly naked on an ER stretcher waiting to be admitted to a hospital bed while wretching into a bowl or using a bedpan with only a flimsy curtain for ‘privacy’, thus being both helpless AND vulnerable to forces beyond our control or ability to understand.

Nothing about this is a level playing field when it comes to social interaction between patients and the hospital staff and the practical necessity to engage an egalitarian decision-making process when we are, 
in fact, in a subservient role.

This makes hospitals and hospitalization a trigger event for women who trace their PTSD to an upsetting, especially if it occurred in relation to previous hospital birth. As a solitary labor patient wearing a hospital gown and lying in bed having painful contractions, concerned about herself and her unborn baby, the inevitable information gap and disparity in social status between the professional hospital staff and the patient is intensely intimidating.

If the laboring woman also felt that her needs, as she experienced and expressed them, were ignored or otherwise not taken seriously, or she was pressured to have interventions she didn’t want and didn’t believe necessary, it often results in a profound loss of confidence in the current system.
This problem is greatly magnified for childbearing women who have a history of sexual abuse or physical assault, for whom the issue of bodily integrity is an everyday problem in all parts of their lives. All these women have compelling and logical reasons for seeking alternatives to routine hospitalization for normal childbirth.
   

Routine hospital Induction at 40 weeks and 4 days — the standard protocol in the U.S. based on ACOG guidelines. However, new guidelines from the recent “ARRIVE” study calls for inducing labor at 39 weeks in all pregnant women – that is 7 days BEFORE their baby is actually due. What you’re seeing in this photo is the new “norm’ for so-called ‘normal’ childbirth in America.

Families seek out midwifery care specifically to avoid the highly medicalized management of normal childbirth in the US, which they experience as similar to trying to give birth in a busy ICU.

Women in the thors of labor experience themselves as tethered to the bed by IV lines, an automatic blood pressure cuff on one arm, a pulse oximeter on a finger of the other hand, two EFM belts around their pregnant belly, with cords leading back to the electronic fetal monitor standing next to their bed, as the mother-to-be lies on her backs, watching unfamiliar members of the hospital staff come and go, while the rest of their family stands out in the hallway, waiting for the baby to be born.

The good news is that Legislative Intent of California Licensed Midwifery Practice Act perfectly matches the needs of these families for a safe and legal ‘alternative’ to a routinely medicalized hospital care and since 1993, has made this risk-reducing form of available to many thousands of California families.

SB 350 was also designed to prevent the many serious problems for childbearing women (and ultimately for society) that are associated with the category of ‘no care’, including an increase in premature births and the dangers of unattended births when state-regulated professional midwifery care is not available.


Tell California Legislators to Vote for Stepping Stones, not Stumbling Blocks

The LMPA was developed to provide a stepping stone to professional maternity care for those healthy women for whom the dominant obstetrical system didn’t work (such as previous traumatized women discussed earlier), or when conventional care was not geographically accessible or acceptable to the family. 

There is no justification for any amendment to the LMPA (such as AB 1308) that consciously puts 
stumbling blocks in the path of healthy childbearing families and uses subterfuge to deny care to the very women who most need access to this traditional form of maternity care. Community-based midwifery provides a safe and acceptable alternative to highly medicalized and expensive hospital care.  Senator Killea to introduced SB 350 (the LMPA) in 1993 specifically to provide access to professional midwifery by self-selected women and their families that deserved to have unwanted and highly medical hospital-based care AND to do so safely by having access to quality maternity services from professionally-trained and state-regulated direct-entry midwives.

Annulment of Midwife’s Scope of Practice and Veto Power over CB woman’s right to self-determination

In 2013, lobbyists for a special interest group — the surgical specialty of obstetrics and gynecology — approached a California legislator with what must have seemed like a logical argument for amending the LMPA. They asked for legislative provisions that:

  • nullified the original scope of practice for licensed midwives
  • repealed the Standard of Care for California Licensed Midwives (SCCLM)
Equally shocking, they dramatically limited the number of essentially healthy childbearing women who, going forward, would legally qualify for midwifery care by nullifying their right to make maternity care decisions for themselves. This was accompanied by a mandatory consultation provision in AB 1308 that required pregnant women with certain (as of this writing still unenumerated) risk factors to be formally evaluated by an obstetrician. This gives the obstetrical profession veto power as to whether or not California licensed midwives as a class would be legally permitted to provide childbirth services to these women.
This provision actually acknowledges the right of a pregnant woman to refuse obstetrical consultation, but specifically expresses in ‘black letter’ law that even if the mother should decline all subsequent obstetrical services, licensed midwives cannot render any pregnancy or childbirth-related care to her. 

Gateway Claims by Special Interest Groups are Neither Accurate or Objective

The so-called ‘commonsense changes’ proposed by lobbyists for this special interest group inserted the warped effects of their own special interests into provisions of the LMPA that define who is ‘permitted’ to receive midwifery care and what kind of care midwives are legally permitted to provide. Another word for any person or group that controls ‘who’ and ‘what’ is “gateway“– like a ‘gateway drug’, it predictably puts you on a downhill path.

AB 1308 usurped 
the legitimate gateways keepers to midwifery care (i.e. professional midwives) by inserting legal language into the LMPA that identified the obstetrical profession as controlling the ‘gateways’ to maternity care as provided by California licensed midwives. As a consequence, AB 1308 specifically eliminated the normal constitutional principle of ‘patient autonomy‘ for healthy childbearing women as it applies to women receiving care from California licensed midwives.

 

This was done by making it illegal for midwives to provide care to pregnant women who had certain risk factors and eliminating the mother-to-be’s right to decide for herself whether she wanted to consult with an obstetrician in relation to these risk factors. Claims that limiting the scope of practice for midwives and eliminating Patients Rights for their pregnant women clients would make childbearing safer was neither accurate or objective.

As you continue to read, it will become clear that organized medicine was and remains more focused on the economic interests of the surgical specialty they represent than the well-being of healthy childbearing women who did not want or need or voluntarily consent to routine obstetrical.  

 



The Scientific Art
 of Midwifery, its History, and its Future

The traditional role of midwives is that of:

an educated observer with emergency response capacity”.

Planned Home Birth attended by California Licensed Midwife Donna Driscoll {1952-2008}

The midwife’s primary duty is to safeguard the normal physiological process while monitoring the well-being of mother and unborn baby. Midwives respond as the need arises, always being careful not to unnecessarily disturb or interfere with the normal biology of spontaneous childbirth as long as things are progressing normally.

This ‘eyes-on, hands-off quality of care describes a professionally-educated and clinically-experienced midwife who is physically present during active labor and able to watch and listen carefully and respond appropriately as the need arises.

This defines physiologically-based care as provided to healthy women with normal term pregnancies. The family’s informed decision to labor in a non-medical setting (parents’ home or free-standing birth center) is based on the use of time-tested physiologic childbirth practices in conjunction with the timely and appropriate use of modern medical science as needed.

Planned OOH birth —  An Integration of “Plan A” and “Plan B”

Community-based midwifery care begins with a family’s informed decision to give birth in a community setting (i.e. an out-of-hospital birth) after their midwife has provided relative information about the risks and benefits normal birth in a non-medical setting for healthy women with a normal pregnancy. Midwives describe this formal  “plan” as having two aspects or possible outcomes, one involving normal birth at home and the other a transfer of care to hospital-based obstetrical services.

Under the 1993 LMPA and the 2006 Standards of Care for California Licensed Midwives (SCCLM), all midwifery clients must consent, a priori, to the use of emergency medical services and/or hospital transfer for themselves or their newborn in event of a birth-related emergency. Midwives and families both see this as an appropriate safeguard to the immediate and long-term well-being of both mother and her unborn/newborn baby requires, which sometimes requires the use of 21st-century medical science as indicated.

The first part of community-based midwifery care — “Plan A” — refers a spontaneous labor at term (after 37 completed weeks of pregnancy) that progresses normally and a mother and fetus who tolerate the various stages of labor and a normal spontaneous birth at home or in a birth center without incident.

If, for any number of possible reasons, things don’t progress as expected or the parents simply request medicalized care, “Plan B” kicks in. This refers to an intrapartum transfer to a local hospital that provides comprehensive obstetrical services. Once admitted, the mother’s care is legally taken over by an obstetrician and the hospital L&D staff.

However, “Plan B” generally includes the continuing supportive presence of her midwife, who accompanies the family to the hospital and usually remains with the mother throughout the remainder of the labor and birth. After the new mother and baby are discharged, the midwife resumes her role as primary caregiver, providing regular postpartum-neonatal home and office visits for at least 6 weeks.

Some midwives also offer ‘2nd-nine-months care’ by seeing the new mother and her infant again at 3, 6 and 9 months. They provide extended postpartum care and social support for new families. This includes helping the new mother deal with the often stressful family dynamics of integrating a newborn into the household, breastfeeding issues, education about normal child development, as well as informally monitoring the mother for signs of postpartum depression that families often don’t pick-up on.  

Midwife-attended birth in Ancient Greece, mother in an upright position (right use of gravity)

Historically, the presence of a trained midwife has always made childbirth orders-of-magnitude safer for laboring women and their unborn, newly-delivered mothers and their newborn babies.

However, it is equally true that prior to the development of modern medical science, neither midwives or doctors were reliably able to detect problems early on, before they became serious complications. When such a serious complication occurred during or immediately after childbirth, the medical profession had very little to offer.

19th-century medical doctors standing around a female patient on a dining room table being used while they perform a “blood-letting“. They have already cut into a large blood vessel in her leg and are letting her bleed into a bowl until pint or more of blood is withdrawn and discarded. Then the doctors would bleed her again (every few hours) until she either got better or died.

But the development of the new biological sciences in the early 20th century made it possible to combine the time-tested methods of physiologic childbirth as provided primarily by midwives with the best advances in obstetrical science, to create (at least in theory) the best of both worlds.

The 20th-century marriage of Traditional Midwifery and Modern Medical Science

The scientific practice of modern medicine, and the incredible ‘medical miracles’ for which it is rightfully famous, originated with the new scientific ability to prevent potentially-fatal bacterial contamination (germs and other pathogens) when performing medical and surgical procedures and to drastically reduce deadly nosocomial (i.e., hospital-acquired) infections from cross-contamination between hospitalized patients themselves and btw patients and the hospital staff.

Before these new scientific discoveries, the bio-hazard nature of hospitals made them extremely dangerous — places to avoid if at all possible — as from 20% to 90% of hospital patients died from post-op infections associated with some surgical procedures.

So it’s fitting that modern maternity care also traces its history back to the discovery of the Germ Theory of infectious disease in 1881, and the risk-reduction strategies (principles of antisepsis) developed by the British surgeon to Queen Victoria, Sir Joseph Lister. This consisted of scrupulous hand-washing, isolation of infected patients, using disinfectants and germicides to wash down hospital walls, floors, furniture, and equipment. Of particular importance in the war against bacteria was the sterilization of surgical instruments and the use of strict “sterile technique” during invasive procedures, such as vaginal exams during labor, and operations such as forceps deliveries.

We don’t usually think of the use of forceps and other invasive medical procedures associated with obstetrical care (such as manual removable of a retained placenta) as a ‘surgical operation’ but technically it is.  Anytime something from the outside world (gloved hand, forceps, another instrument, a surgical sponge, etc) is introduced into a sterile body cavity, it is a ‘surgical procedure’ and requires the use of surgically ‘sterile’ technique in which everything that touches the patient must be uniformly sterile.

Three cheers for the modern biological sciences & the physician-scientists that brought this about!

British surgeon Sir Joseph Lister who in 1865 developed the “Principles of Sepsis” and “strict sterile technique” used during surgical operations. He was knighted by Queen Victoria and became her personal physician-surgeon.


Science-based Maternity Care

What we now refer to as “maternity care”, which includes the new invention of prenatal care, wasn’t developed until early in the 20th century.

The purpose of maternity care is to preserve the health of already healthy childbearing women. Mastery in this field means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. In the US, 90% of women who become pregnant every year are healthy and 70% to 80% are still healthy and enjoying a normal healthy pregnancy with a single fetus in a head-down position nine months later.

The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of medical interventions if necessary provides the best outcome with the fewest number of medical/surgical procedures and least expense to the healthcare system and lowest rate of iatrogenic and nosocomial complications.

The development of prenatal care in the early 20th century allowed professionally-trained midwives and doctors, for the first time, to routinely risk-screen pregnant women at each antepartum visit. This included lab work to see that the mother-to-be wasn’t dangerously anemic or infected with hepatitis or a sexually-transmitted disease.

The pregnant woman’s blood pressure and urine were regularly checked for evidence of pre-eclampsia and diabetes, while the unborn baby’s growth, position, and heart rate were also monitored. This preventative care allowed both doctors and midwives to detect and correct small problems before they became serious complications. Equally important, it helped to identify women with serious medical conditions, such as heart or kidney disease, or high-risk pregnancies so they could be immediately referred to an appropriate specialist.

Quality prenatal care saves the lives of mothers and babies and costs a hundred-fold less than the bills for intensive hospital care and other medical treatments for complications that could have been prevented if the mother had received good prenatal care.

 

During the 20th century, there has been a steady improvement in maternal-infant outcomes around the world. Many wrongly assume these improved outcomes were was the result of the highly-medicalized care for healthy women in the world’s richest countries, particularly the US.

 

However, these good outcomes turn out to be the result of an improved standard of living, general access to healthcare and medical services and, in particular, the preventive use of people-intensive, low-tech maternity care.

This describes the prophylactic use of eyes, ears, hands and a knowledge base by maternity care professionals, who are able to screen for risk and refer for medical evaluation as needed.

The best (and smartest!) form of maternity care integrates the principles of physiological management with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies, with obstetric interventions reserved for those with complications or if requested by the mother

This is the best ‘medicine’ for normalizing childbirth in a healthy population.      @last edit 03-12-2018@


Continue to Part Two ~ The Art & Science of Modern Midwifery in California

Associated Topic –> The Physiological Manage of Normal Childbirth in Healthy Women ~ What, how, and why it’s usually not provided in hospital obstetrical departments

 

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Roxanne Potter-Cummings, CNM Santa Cruz, CA b.1950 ~ d.2016

Why CALM, CCM & C-FAM (you too we hope) is opposed to California senate bill 457


The California Nurse-Midwives Association and the California Association of Licensed Midwives (CALM) stand together in opposition to this bill.

CALM is opposed because:

This bill, which is being promoted by anti-midwife physician groups, drastically reduces the scope of practice for both Licensed Midwives and Certified Nurse-Midwives and severely restricts access to out-of-hospital maternity care for all families in the state of California.

This bill mandates that women with potential risk factors who are planning an out-of-hospital birth must undergo a medical examination by an OB/GYN and seek their permission to remain under midwifery care. Midwives who continue to provide care without physician permission will be charged with unprofessional conduct.

This bill denies out-of-hospital midwifery care to women who have had either a cesarean section or any other previous abdominal surgery, including laparoscopy or laparotomy, for a broad range of conditions, from hernia and appendicitis to gall bladder removal.

This bill mandates that women must give birth in the hospital if they live more than 20 minutes from a hospital, which will impose even more limits on access to care for California’s rural families.

This bill mandates that women who are planning an out-of-hospital birth must be presented with so-called “informed consent” documents that are based on junk science.

SnakeCatchBird_small

SB 457 strikes down major portions of the Licensed Midwifery Practice Act of 1993. In addition, it denies essentially healthy childbearing women the right to determine for themselves *which set* of risks is most consistent with the parents’ values, goals, finances, and geographical considerations — the risks of a professionally-attended normal childbirth in a non-medical setting, OR the risks associated w/ typical obstetrical management in a hospital .

This bill strikes down the current law that gives Licensed Midwives the legal ability to obtain both routine and life-saving tests and medications, putting mothers and babies at unnecessary risk.

This bill strikes down the current law allowing Licensed Midwives to provide family planning services, denying women access to fundamental and essential reproductive health care.

This bill represents a major setback for maternal and infant health in the state of California by denying families access to care, violating their personal decision-making rights, and imposing state-mandated obstetrical care on women who are seeking out-of-hospital birth, midwifery, and other safe and cost-effective models of care.


All calls are needed, but those in Senator Bates’ district or other Republican districts are CRITICAL.

Respectfully request that Senator Bates NOT introduce anti-midwifery legislation planned for SB 457.

If you live in Senator Bate’s district, your calls TODAY are critical. Please share this alert with other midwives and midwifery supporters in your community NOW.

Senator Bates’ Sacramento Office: 916-651-4036

The message: Please respectfully request that Senator Bates NOT introduce anti-midwifery legislation planned for SB 457.

OLYMPUS DIGITAL CAMERA

Kate Bowland, CNM; providing midwifery care in Santa Cruz, CA since 1972 {retired}

If you live in a Republican district, your calls are particularly important TODAY. Find your state senator HERE and call NOW.

The message from me, and Kate, Rox, Karen, Rosanna, Hope and many other midwives and the healthy families they serve: 

Please ask your state senator if he or she would respectfully request that Senator Bates NOT introduce anti-midwifery legislation planned for SB 457.

Michael Baker FRM. CIA Operative ~ interviewed on MSNBC 04-08-2017

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Identifying the real dangers of normal childbirth in healthy women

Links to previous posts for: Part One, Part Two, Part Three

When it comes to identifying the actual dangers associated with normal childbirth in a healthy childbearing population, the American public and a majority of the medical profession frequently see dangers where there are none, while failing to identify the actual risks.  This perspective sees childbirth in the human species as a defective or pathological aspect of female biology. It sees physiologically-based management as old-fashioned, inadequate, dangerous, irresponsible and all-together a bad idea.

As a result, most people believe that medicalizing normal childbirth is an absolute necessity, that each increased level of medicalization actually makes childbirth substantially safer and that an elective Cesarean delivery is the safest of all options, as it totally circumvents all the unpredictable dangers of normal birth.

Actual Facts: The common complications of normal childbirth in healthy women living in developed countries with functional healthcare systems are relatively rare and relatively easily and safely dealt with by modern medicine.

Artificial Dangers: However, when the same medical and surgical interventions that are so successful at treating the relatively rare (but real) complications of childbirth are routinely used on healthy women, it introduces the unnecessary risk associated with iatrogenic and nosocomial (hospital-related) complications.

As a result, highly-medicalized care in healthy women is associated with a 2- to 10-fold increase in medical interventions (EFM, immobilization in bed, induction, Pitocin-augmented labors) and Cesarean surgery (currently 33%). Unnecessary medicalization of labor and birth in healthy women is associated with increased maternal morbidity (serious complications) and elevated rate of maternal mortality in the US.

Both of easily preventable dangers are the result of the general misunderstanding of the real risks of childbirth in the 21st century.

The real elements of safety & danger as revealed by “Five Models, Five Perspectives, Five Insights:

The real source of danger for healthy childbearing women in the 21st century is lack of access to a functional health care system (Afghanistan, sub-Sahara Africa, etc) or a failure to use available maternity services, whatever the reason. This can be due to economic issues (no health insurance, trying to save money), religious or cultural beliefs, immigrations status, other personal circumstances (such as PTDS), or the result of a state-sanctioned denial-of-services by hospitals, doctors and midwives.

State-sanctioned denial of maternity care services occurs when the laws in a state allow hospitals to have policies that legally (but unethical all the same) “ban” vaginal childbirth. The result is to force unwanted Cesarean surgery on certain categories of healthy women, such as those with a ‘big’ baby, having twins, a breech baby or who previously had a Cesarean delivery. A similar legal but unethical denial-of-services occurs when malpractice carriers are allowed to lawfully prohibit obstetrical groups from providing vaginal birth services to this same subset of health women who were expecting to have a normal birth.

The last type of denial-of-services occurs when state laws for professional midwives purposefully restrict their legal ability to provide care to a subset of childbearing women. Typically this applies to essentially healthy women who have an identified risk but are decline to be medicalized against their wishesThis frequently happens to previous-CS mothers who expected to have a normal vaginal birth but finds that all the hospitals within reasonable driving distance offer only an unwanted and highly risky repeat Cesarean section.

According to constitutional law and as formally acknowledged by the American College of Obstetricians and Gynecologists (ACOG opinions #664, 214, 166 and earlier versions), adult women have a legal and ethical right to self-determination when it comes to all aspects of maternity care and childbirth services.  But very often these principles are not applied to healthy childbearing women who find themselves in these situations.

When trapped between the Devil and the Deep Blue Sea by a lawful but unethical state-sanctioned denial-of-services, many of these families either seek care from lay midwives or plan an unattended birth; both decisions will unnecessarily increase easily preventable risks to mother and baby.

These are completely PREVENTABLE risks.

Part 3 (of 3)

The Silent Third Partner:

Parental Decision-Making and how the ethical and legal rights of parents to make medically unpopular or unwise choices may result in preventable neonatal mortality and how that aspect is routinely ignored in studies conducted on the relative  safety of OOH birth services.  

In regard to safety vs. danger in normal childbirth, we so far have focused on whether the mother-to-be had routine prenatal care vs. “no care“, an attended birth vs. unattended, whether the birth attendant was a MD or midwife, and whether the planned place-of-birth was in- or out-of-hospital.

 

Unacknowledged research bias on OHH Mfry Care

Of these four binary “yes/no” circumstances, two of them reflect choices made by parents — for example, to have or not have prenatal care; to have an attended vs. purposefully-unattended OOH birth — while the last two are practitioner-centric.

From the standpoint of research on OOH setting, the choice of place-of-birth is usually (though illogically) seen as a practitioner issue. The unspoken assumption is that birth attendants decide the choice of setting since each category of practitioner generally refuses to provide care to childbearing families who do not plan to give birth in the setting preferred by that birth attendant. The medical profession is firmly convinced that the whole issue of relative safety would go away in an instant if midwives would just get hospital privileges and thereafter refuse to attend home births.

That however begs the point, which is our current obstetrical-centric system as applied to healthy childbearing women.  In the US, our hospital-based system steadfastly declines to provide the quality of care that families choosing OOH birth services are seeking and have an ethical right to receive — a science-based, cost-effective model specifically configured to meet the full spectrum of physical and practical needs of healthy childbearing women with normal pregnancies who do not want, need or benefit from medicalized services.

Safety research on OOH birth leaves parental decision-making out of the equation

Of the three categories of decision-makers noted above (parents, midwives & doctors), the studies on PHB/OOH only focus on the last two by only contrasting MD care vs MF care, and/or hospital vs. OOH/PHB. Regrettably, this makes relative safety into a win-loose contest: Hospital-based obstetricians versus Midwives providing care in OOH settings.

In general, midwives don’t get full credit when the outcome is good (just “lucky”), nor are they adequately credited for reducing the medical interventions 2-to-10-fold; they are however fully blamed for any possible professional inadequacy along with problems associated with an OOH environment (transfer time that delays emergency treatment).

On the other hand, the obstetrical profession is credited with all good outcomes but not held responsible for problems associated with the hospital environment and associated problems such as a high Pitocin-augmentation and C-section rate, medication mistakes, antibiotic-resistant infections and other nosocomial complications.

In both instances, parental decision-making is left out of the equation entirely, as is an equal focus on  the risks and benefits of each environment — hospital as well as OOH settings. Personally, I think that is the wrong way to look at this issue, but realistically the identified ‘responsible party’ in studies on this topic is still obstetricians and midwives.

In theses instances, it’s assumed that the outcomes of midwife-attended, planned OOH births had little or nothing to do with lawful decisions make by the parents that resulted in acts or omissions that may have affected outcomes.

During prenatal care, this includes their decision to decline routine labs, pregnancy-dating and level II ultrasounds, genetic testing & termination (or refusal to terminate) a pregnancy affected by potentially lethal birth defects. During the intrapartum period, they may not tell the midwife when the water breaks before labor, or decline prophylactic antibiotic treatment when the mother is GBS+. So far as i know, only the Snowden study on PHB/OOH birth in Oregon has directly acknowledged that parental decision-making often plays a substantial role in adverse events and bad outcomes.

However, this focus on the birth attendants reduces parents to mere by-standers in someone else’s drama, and exempting them of any responsibility — good or bad — for the outcome.

In this last section, we will examine the impact of parental choice that run counter to the wishes or recommendation of their care providers or standard medical advise and in some cases, may have resulted in what appeared to be a preventable stillbirth or neonatal death.

Slient Partners: The unacknowledge role of Parental decision-making in childbirth outcomes

FACTS: The routine use of ultrasound and prenatal genetic screening in the hospital cohort, in conjunction with the termination of affected pregnancies during the pre-viable state, slightly lowers the rate of perinatal and neonatal mortality when compared to the subset of families who choose OOH birth. This is due to a reduced number of babies in the hospital cohort with lethal anomalies who are carried to term.

Families that choose non-medical maternity care are statistically less likely to utilize prenatal genetic and ultrasound screening or to terminate affected pregnancies when indicated. One study in PHB in Washington State (1996) documented a disproportionate increase NNM due to congenital anomalies, not all of which were incompatible with life. Among this specific sub-set of non-testing parents, prenatal diagnosis and planned hospital care would have reduced (but not eliminated) the incidence of neonatal mortality. However, this is a patient choice and is not a provider or place-of-birth issue.

In regard to the great debate about safety, it is useful to realize that birth-related morbidity and mortality can be time-shifted, place-shifted and practitioner-shifted, but they cannot be eliminated. In other words, increasing rates of pregnancy termination reduces neonatal mortality rates but obviously does not reduce overall perinatal mortality.  There is nothing that birth attendants can do or not do that reliably, and with economically sustainability, can create a condition of zero risk for both mother and baby 100% of the time.

The risk-benefit continuum among the 4 responses to normal childbirth and the 3 types of birth attendants:

Simple access to prenatal care, on-going risk-screening and physiological management of active labor, birth and immediate postpartum-neonatal period by experienced birth attendants of all categories improved outcomes by orders of magnitude. Here is the breakdown for each type of birth attendant and both in and out-of-hospital settings.

NO CARE:

The most startling conclusion is the consequences of “no care”. Lack of prenatal care, no skilled birth attendant present during labor and birth and not having or not using emergency care when indicated is unconscionably dangerous and represents a failure of society at some level. The total absence of medical and maternity services, whether by religious or personal choice, due to poverty or cultural beliefs, can turn the otherwise normal biology of pregnancy and childbirth into a lethal condition.

LAY MIDWIVES:

Many people would have assumed that the care of lay midwives would have been little better than unattended births but they would have been very mistaken. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to the control group.

When it comes to ‘value-added’ above the background biological hazard, lay midwives added the most value of any category of birth attendant.  These good outcomes were achieved by providing childbearing women with prenatal care, on-going risk-screening and referring those with serious medical or pregnancy complications to obstetrical services. Mothers and their unborn babies were monitored during active labor by capable midwives who recognized medical problems and arranged timely transfer of patients with complications to the obstetrical service at the county hospital.

This straight-forward access to prenatal care, risk screening, transfer as indicated and physiological management during labor, birth and postpartum-neonatal period as provide by lay midwives was able to reduce perinatal mortality by 20 to 40 times compared to the mortality statistics for control group. This substantial feat was accomplished at a small fraction of the expense and was able to lower neonatal mortality to a rate similar to that of professional midwives and a maternal mortality rate equivalent to hospital-based-obstetrical care.

Within the structured healthcare systems of North American and the formal reimbursement scheme by governments and insurance carriers, expansion of services by lay birth attendants would not be a viable option. Our educated population rightfully expects their healthcare providers to be professionally trained, regulated by the state, able to carry emergency drugs and equipment and to repair simply perineal lacerations as a part of their normal scope of practice.

Nonetheless, lay midwives are an eager and reliable group that should not be overlooked. They are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries and among groups that are for any reason excluded from the official health care system in developed countries. It is illogical and unwise to criminalize this group.

PROFESSIONAL MIDWIVES:

In study #3 state-regulated direct-entry midwives had no maternal mortality and a neonatal mortality rate of 2.6 per 1,000 (including fatal birth defects), which was ever-so-slightly better that the lay midwives and in the same general range as hospital-based obstetrical care for low and moderate-risk women. However, childbearing women cared for by professional midwives had 2 to 10 times less obstetrical intervention than medicalized hospital care and a 6-fold decrease in Cesarean section (under 4%). All of these good outcomes were achieved at a small fraction of the expense of orthodox obstetrical care.

In study #4, the Canadian direct-entry midwives were fortunate to be providing care in a providence that had an integrated model of care with generally cooperative and complimentary relationships between midwives and physicians. Midwives in several parts of Canada have hospital admitting and practice privileges, so healthy women have the option of a planning a midwife-attended hospital birth. This also allows for continuity of  care for transfers from home to hospital when the mother-to-be does not require obstetrical management or operative delivery. When the services of an obstetrician are needed, this articulated system provides for a seamless transfer of care and ‘no-fault’ receptions.

Last but not least, these statistics are for a subset of childbearing women — the lowest of low-risk women. This is a patient population with good access to and use of prenatal screening and for whom all diagnosable congenital anomalies have been eliminated from this cohort. Neonatal deaths for midwife attended PHB in this population are the very lowest of all stats for normal birth in any setting — NNM per 1,000 of 0.35 for births planned home births, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births.

These are ideal circumstances and while we all aspire to them, they cannot be replicated 100% of the time by 100% of the childbearing populations. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare.

With the rarest of exceptions, this general principle applies to healthy childbearing women. Assuming that the mother-to-be is fully informed by her birth attendants, she has the right to decline prophylactic medicalization and choose instead (or accept) the increase risk of a specific pregnancy or intrapartum circumstances that puts her into a moderate risk category  — for example, a small fibroid, a large baby, vaginal birth after a Cesarean, prolonged rupture of membranes, meconium, or a post-dates baby with reactive NST.  It is necessary for the maternity care system to acknowledge the constitutional right of adult women to continue receiving birth-related services even when they are not totally ‘ideal’ candidates for OOH care.

The alternative is to put many women between the Devil and Deep Blue Sea by denying access to professional OOH care. This forces them to choose between medicalization they do not want, and in actual fact may not benefit from, or having unattended births (the risks of which have already been identified). The other problematic possibility is that women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives her of access to adequately trained attendants and medical back-up arrangements but also creates another group of unregulated lay midwives, which is both unnecessary and unwise.

The better strategy is to acknowledge that moderate risk women have a constitutional right to have professional services for an OOH birth. The statistical record of a mixed-risk population (low plus moderate-risk women) consistently demonstrates a NNM rate between 1.5 and 2.6 per 1,000, irrespective of birth attendant or birth setting.

HOSPITAL-BASED CARE:

Institutionally-based obstetrical care appeared to have improved neonatal mortality ever so slightly (approximately 1.5 per 1,000) as compared to the lay attended group (3:1,000) and professional midwives (2.6:1,000, but this small gain was offset by a dramatically increasedCesarean section rate of 32% and drastically increased cost of care. This escalating CS rate has been associated with the current upward trend in maternal mortality (MM) by other researchers.

In that regard, physiologically-based forms of care, which lower the incidence of Cesarean, also reduce rates of maternal mortality. While no family or birth attendant should ever be forced to choice between the life of the baby and that of the mother, we also must be sure that enthusiasm for the lowest possible neonatal mortality statistics does not increase the risk to the childbearing woman and result in avoidable maternal mortality.

High-tech, high-cost, highly interventionist obstetrical care for healthy women does not appear to improve combined mortality rates for mothers and unborn or newborn babies. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of surgical delivery.

Bottom Line: Hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.

As measured by the outcome statistics for the 3 categories of birth attendants: lay midwife-attended, professional midwife-attended and hospital-based, medically attended — the most efficacious strategy for preventing maternal and perinatal mortality and morbidity consists of the three simple already identified aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth. This was associated with  prenatal care, risk-screening, transfer to medical services as indicated, birth attendant skilled in physiologic care present during the intrapartum, postpartum-neonatal period and appropriate use of emergent and comprehensive medical services as necessary.

Evidence-based maternity care by birth attendants trained in physiological (non-interventive) management achieved “maximal results with minimal interventions” by a wide margin. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.

To paraphrase the popular African saying, it takes a village of skilled and knowledgeable people to support the safe passage of mother and baby thru pregnancy and birth.

Part 2 (of 3)

Click here read part 1 ~ Identifying the real dangers of normal childbirth in the 21st-century

Safety & the maternity-care continuum in an essentially healthy population

Two kinds of data are required to intelligently determine if the current configuration of medical and midwifery care is making the kind of cost-effective contribution that economists refer to as ‘value added’. In order to identify “value-added”, we must first identify the innate riskiness of normal childbearing and directly quantify the relative benefits of each category of maternity care.

This requires baseline data for “no care” in an essentially healthy US population, as well as outcome statistics for each type of birth attendant. Having done that, the essential qualities of maternity care can be distinguished from customary practices not directly associated with better outcomes for mothers and babies.

The ultimate goal is to test the validity of all current maternity care policies, protocols and practices in regard to safety, cost-effectiveness and patient satisfaction and to arrive at ‘standard care’ characteristics. This would integrate the principles of physiological management with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies, with obstetric interventions reserved for those with complications or if requested by the mother. Having scientifically identified ‘standard care’ characteristics, this model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.

Childbirth risks in healthy women & policies that reduce them

In searching for the essential qualities of safe and cost-effective maternity care, I have identified 5 useful sources – 4 published studies in combination with a consensus of the research literature for hospital-based maternity services in the US. These included:

(1) a contemporary study of purposefully unattended births & rejection of necessary emergent care
(2) a retrospective study of lay midwife-attended OOH w/ access to comprehensive medical service
(3) a prospective study of professional midwife-attended OOH w/ access to comprehensive medical services
(4) a prospective Canadian study that contrasted outcomes for a select groups of low-risk women that gave birth under three different circumstances (a) OOH setting under the care of direct-entry midwives, (b) in hospital under the same category of midwives and (c) in hospital by MDs
(5) a configuration of hospital-based obstetrical studies of medically-managed hospital births in low and moderate risk women by obstetricians, FP physicians and certified nurse- midwives.

CONTROL GROUP: The study of unattended birth functions as a ‘control group’ that allows comparison of ‘care’ versus ‘no care’. Then we can compare the 3 major groups of birth attendants to one another and to the ‘no care’ cohort.

Taken together these studies provide information on the biological background rate of maternal and perinatal mortality and morbidity when all the benefits of modern biological sciences are absent, inaccessible or rejectedby a childbearing population due to cultural traditions or religious beliefs.

The poor outcomes for purposefully unattended birth in the US in an educated and essentially healthy population are consistent with available statistics for maternal-infant mortality in the late 19th and early 20th century in the US, and the current high maternal mortality rates in developing countries such as Afghanistan, Ethiopia and the Gambia. The major cause of MM in this first-world cohort was hemorrhage and infection and establishes a background rate of biological risk that is independent from poverty, malnutrition and other factors specific to deprivation.

CONVENTIONAL OBSTETRICS: At the other end of the scientific continuum, this collection of studies also helps us to distinguish between maternity care policies and practices that benefit healthy women and those non-productive traditions, customs and provider preferences that increase the economic cost, but do not directly contribute to improved maternal-infant outcomes.

Five Models, Five Perspectives, Five Insights

Study #1 Perinatal & maternal mortality in a religious group avoiding obstetric care – Am Jour Obst Gyne 1984 Dec 1: 150(7):926-31:

This control group consists of women with the same general health and demographic characteristics that are seen in the CDC birth registration data. This is predominately healthy, white, middle-class women who had economic access to all categories of maternity care providers and settings, but in this case, purposefully choose unattended births. Data on this group of unattended home births came from Indiana state mortality statistics for a fundamentalist religious group that rejected all forms of medical care under all circumstances – no prior diagnosis or treatment of chronic medical problems, no risk-screening of mothers during pregnancy, no prenatal care, no trained attendant during childbirth and no emergency transfer of mother or baby with life-threatening complications to a medical facility – a situation similar to rural parts of the developing world.

Out of 344 births, the unattended group had 6 maternal deaths and 21 perinatal losses. The baseline mortality rate for unattended childbirth was one maternal death per 57 mothers or MMR of 872 per 100,000 live births (92 times higher than Indiana’s MMR for the same period) and one perinatal loss for every 16 births or PNM rate of approximately 45 per 1,000.

Study #2: “Home Delivery & Neonatal Mortality in North Carolina”, Claude Burnett, Judith Rooks; JAMA, Dec 19, 1980, Vol. 244, No. 24, p. 2741-2745:

Planned home birth (PHB) in an impoverished and medically-indigent minority population attended by experienced lay midwives. These demographically high-risk maternity patients were risk-screened one time by a public health officer prior to being approved for PHB under the care of a lay midwife. However, state laws did not authorized non-nurse midwives to carry oxygen or emergency anti-hemorrhagic drugs (Pitocin) or to suture perineal tears. These county-registered midwives were required to transfer patients with complications to a local hospital in an appropriate and timely manner. The lay midwife-attended group had no maternal deaths and 4 neonatal losses per 1,000 (including 2 fatal birth defects).

Note: This study also reported the perinatal mortality rate for medically indigent women in the same rural regions of North Carolina who delivered unattended, often because local hospitals turned away laboring women who did not have the prescribed ‘cash in hand’. These unattended births had a dramatically increased perinatal mortality rate ranging from 30 to 120 stillbirth and neonatal deaths per 1,000, a perinatal mortality rate consistent with 3rd world countries and unattended births among the religious group in Indian.

This highlights the preventive value of physiologically-based pregnancy and childbirth services and the equally important access to medicalized maternity care during pregnancy as indicated and the ability to call on comprehensive medical services during the intrapartum and immediate postpartum-neonatal period whenever necessary. Compared to the combined mortality statistics for the control group, the care of these lay midwives saved the lives of 14 mothers and 58 babies. If their care were a drug or medical device, it would be illegal for every childbearing women not to have one of them.

Study #3: Outcomes of planned home births with certified professional midwives: large prospective study in North America; Kenneth C Johnson, senior epidemiologist; BMJ 2005;330:1416 (18 June 2005)

Planned home birth (PHB) in a generally healthy population as attended by nationally-certified direct-entry (non-nurse) midwives in the year 2000. All clients were risked-screened and received prenatal care and those with medical or pregnancy complications were referred to medical services. Professional midwives monitored maternal vital signs and fetal heart tones during labor and were authorized to carry emergency supplies such oxytocin (Pitocin + Methergine), IV fluids, oxygen, neonatal resuscitation equipment and also to suture perineal lacerations. Twelve percent of PHB patients were transferred to the hospital during labor or after birth, the majority of
 whom were first-time mothers. Cesarean rate was < 4% for PHB women hospitalized during labor. This group had no maternal deaths and 2.6 neonatal losses per 1,000 (including lethal birth defects).

Study #4: Outcomes of planned home birth with midwives versus planned hospital birth with midwife or physician; Janssen PA, Saxell L, Page LA, et al. CMAJ 2009;181:377-383:

A 5-year Canadian  prospective study published in 2009 compared the outcomes of PHB in British Columbia attended by professional direct-entry midwives btw 2000 and 2004. It compared planned hospital births also attended by this same category of professional midwives and a matched low-risk cohort of physician-attended hospital births. They found that the risk of perinatal death associated with PHB attended by midwives did notdiffer significantly from the low rate associated with planned hospital birth. The study also found that women who planned a home birth had a reduced number of obstetric interventions and adverse maternal outcomes.

The neonatal death rates per 1,000 births were 0.35 for midwife-attended planned OOH birth, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births. Maternal mortality for all three groups was zero. Inclusion in the two hospital categories required the childbearing women to have the same low risk-based characteristics as those who were planning to labor at home. These finding echoed a Dutch study published in July that also found a planned home birth to be as safe as a planned hospital birth, provided that a well-trained midwife is available, transportation and medical referral system is in place, and the mother is at low risk of developing any complications.

The authors concluded: “… (the) study showed that planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and adverse maternal outcomes compared with planned hospital birth attended by a midwife or physician”.

#5 Neonatal mortality rates for planned hospital birth as reflected in a consensus of scientific literature, plus CDC birth registration stats for birth after 37 completed wks and data on obstetrical intervention levels in general population from the “Listening To Mothers” survey, Childbirth Connection; 2002 and 2006:

Planned hospital services for low and moderate risk women — labor attended by a professional nursing staff, routine intrapartum use of continuous electronic fetal monitoring (93%), IVs (86%) and epidurals (63%); birth conducted as a surgical procedure by a physician or certified nurse midwife. Medical intervention rate for this group was 99%; aggregate surgical intervention rate was 70% (episiotomy, forceps, vacuum extraction and Cesarean section). The CS rate was approximately 25% in 2002 (now 32%). The scientific literature reported neonatal mortality for obstetrically-managed hospital birth for low-risk women to range from a low of 0.79 to 4.1, with an average NNM rate of 1.5 per 1,000. 

Click here for Part three: Patient-choice issues of genetic testing and termination of affected pregnancies; Risk-benefit btw the 3 major categories of birth attendants, and additional comments

The patient-choice issue of genetic testing & termination

The routine use of ultrasound and prenatal genetic screening in the hospital cohort, in conjunction with termination of affected pregnancies during the pre-viable state, slightly lowers the rate of perinatal and neonatal mortality when compared to the sub-set of families who choose OOH birth. This is due to a reduced number of babies in the hospital cohort with lethal anomalies who are carried to term.

Families that choose non-medical maternity care are statistically less likely to utilize prenatal genetic and ultrasound screening or to terminate affected pregnancies when indicated. One study in PHB in Washington State (1996) documented a disproportionate increase NNM due to congenital anomalies, not all of which were incompatible with life. Among this specific sub-set of non-testing parents, prenatal diagnosis and planned hospital care would have reduced (but not eliminated) the incidence of neonatal mortality. However, this is a patient choice and is not a provider or place-of-birth issue.

In regard to the great debate about safety, it is useful to realize that birth-related morbidity and mortality can be time-shifted, place-shifted and practitioner-shifted, but they cannot be eliminated. In other words, increasing rates of pregnancy termination reduces neonatal mortality rates but obviously does not reduce over all perinatal mortality.  There is nothing that birth attendants can do or not do that reliably, and with economically sustainability, can create a condition of zero risk for both mother and baby 100% of the time.

The risk-benefit continuum among the 4 responses to normal childbirth and the 3 types of birth attendants:

Simple access to prenatal care, on-going risk-screening and physiological management of active labor, birth and immediate postpartum-neonatal period by experienced birth attendants of all categories improved outcomes by orders of magnitude. Here is the breakdown for each type of birth attendant and both in and out-of-hospital settings.

NO CARE: The most startling conclusion is the consequences of “no care”. Lack of prenatal care, no skilled birth attendant present during labor and birth and not having or not using emergency care when indicated is unconscionably dangerous and represents a failure of society at some level. The total absence of medical and maternity services, whether by religious or personal choice, due to poverty or cultural beliefs, can turn the otherwise normal biology of pregnancy and childbirth into a lethal condition.

LAY MIDWIVES: Many people would have assumed that the care of lay midwives would have been little better than unattended births but they would have been very mistaken. Of the three birth attendant categories, the physiologically-based (i.e., non-medical) care by lay midwives to a demographically at-risk population demonstrated the most extraordinary level of cost-effectiveness and reduction in both maternal and perinatal mortality when compared to the control group.

When it comes to ‘value-added’ above the background biological hazard, lay midwives added the most value of any category of birth attendant.  These good outcomes were achieved by providing childbearing women with prenatal care, on-going risk-screening and referring those with serious medical or pregnancy complications to obstetrical services. Mothers and their unborn babies were monitored during active labor by capable midwives who recognized medical problems and arranged timely transfer of patients with complications to the obstetrical service at the county hospital.

This straight-forward access to prenatal care, risk screening, transfer as indicated and physiological management during labor, birth and postpartum-neonatal period as provide by lay midwives was able to reduce perinatal mortality by 20 to 40 times compared to the mortality statistics for control group. This substantial feat was accomplished at a small fraction of the expense and was able to lower neonatal mortality to a rate similar to that of professional midwives and a maternal mortality rate equivalent to hospital-based-obstetrical care.

Within the structured healthcare systems of North American and the formal reimbursement scheme by governments and insurance carriers, expansion of services by lay birth attendants would not be a viable option. Our educated population rightfully expects their healthcare providers to be professionally trained, regulated by the state, able to carry emergency drugs and equipment and to repair simply perineal lacerations as a part of their normal scope of practice.

Nonetheless, lay midwives are an eager and reliable group that should not be overlooked. They are able to provide safe care within a cost-effective system that dramatically improves mother-baby safety in developing countries and among groups that are for any reason excluded from the official healthcare system in developed countries. It is illogical and unwise to criminalize this group.

PROFESSIONAL MIDWIVES: In study #3 state-regulated direct-entry midwives had no maternal mortality and a neonatal mortality rate of 2.6 per 1,000 (including fatal birth defects), which was ever-so slightly better that the lay midwives and in the same general range as hospital-based obstetrical care for low and moderate-risk women. However, childbearing women cared for by professional midwives had 2 to 10 times less obstetrical interventionthan medicalized hospital care and a 6-fold decrease in Cesarean section (under 4%). All of these good outcomes were achieved at a small fraction of the expense of orthodox obstetrical care.

In study #4, the Canadian direct-entry midwives were fortunate to be providing care in a providence that had an integrated model of care with generally cooperative and complimentary relationships between midwives and physicians. Midwives in several parts of Canada have hospital admitting and practice privileges, so healthy women have the option of a planning a midwife-attended hospital birth. This also allows for continuity of  care for transfers from home to hospital when the mother-to-be does not require obstetrical management or operative delivery. When the services of an obstetrician are needed, this articulated system provides for a seamless transfer of care and ‘no-fault’ receptions.

Last but not least, these statistics are for a sub-set of childbearing women — the lowest of low risk women. This is a patient population with good access to and use of prenatal screening and for whom all diagnosable congenital anomalies have been eliminated from this cohort. Neonatal deaths for midwife attended PHB in this population are the very lowest of all stats for normal birth in any setting — NNM per 1,000 of 0.35 for births planned home births, 0.57 for midwife-attended hospital births, and 0.64 for physician-attended hospital births.

These are ideal circumstances and while we all aspire to them, they cannot be replicated 100% of the time by 100% of the childbearing populations. Democratic societies recognize the principle of autonomy for mentally competent adults in regard to healthcare.

With the rarest of exceptions, this general principle applies to healthy childbearing women. Assuming that the mother-to-be is fully informed by her birth attendants, she has the right to decline prophylactic medicalization and choose instead (or accept) the increase risk of a specific pregnancy or intrapartum circumstances that puts her into a moderate risk category  — for example, a small fibroid, a large baby, vaginal birth after a Cesarean, prolonged rupture of membranes, meconium, or a post-dates baby with reactive NST.  It is necessary for the maternity care system to acknowledge the constitutional right of adult women to continue receiving birth-related services even when they are not totally ‘ideal’ candidates for OOH care.

The alternative is to put many women between the Devil and Deep Blue Sea by denying access to professional OOH care. This forces them to choose between medicalization they do not want, and in actual fact may not benefit from, or having unattended births (the risks of which have already been identified). The other problematic possibility is that women who are refused care by regulated birth attendants will simply choose unregulated ones. This not only deprives her of access to adequately trained attendants and medical back-up arrangements but also creates another group of unregulated lay midwives, which is both unnecessary and unwise.

The better strategy is to acknowledge that moderate risk women have a constitutional right to have professional services for an OOH birth. The statistical record of a mixed-risk population (low plus moderate-risk women) consistently demonstrates a NNM rate between 1.5 and 2.6 per 1,000, irrespective of birth attendant or birth setting.

HOSPITAL-BASED CARE: Institutionally-based obstetrical care appeared to have improved neonatal mortality ever so slightly (approximately 1.5 per 1,000) as compared to the lay attended group (3:1,000) and professional midwives (2.6:1,000, but this small gain was offset by a dramatically increasedCesarean section rate of 32% and drastically increased cost of care. This escalating CS rate has been associated with the current upward trend in maternal mortality (MM) by other researchers.

In that regard, physiologically-based forms of care, which lower the incidence of Cesarean, also reduce rates of maternal mortality. While no family or birth attendant should ever be forced to choice between the life of the baby and that of the mother, we also must be sure that enthusiasm for the lowest possible neonatal mortality statistics does not increase the risk to the childbearing woman and result in avoidable maternal mortality.

High-tech, high-cost, highly interventionist obstetrical care for healthy women does not appear to improve combined mortality rates for mothers and unborn or newborn babies. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of surgical delivery.

Bottom Line: Hospital-based obstetrical care for healthy women with normal pregnancies was not statistically safer or more cost-effective.

As measured by the outcome statistics for the 3 categories of birth attendants: lay midwife-attended, professional midwife-attended and hospital-based, medically attended — the most efficacious strategy for preventing maternal and perinatal mortality and morbidity consists of the three simple already identified aspects of maternity care that balance safety and cost-effectiveness and apply regardless of place of birth. This was associated with  prenatal care, risk-screening, transfer to medical services as indicated, birth attendant skilled in physiologic care present during the intrapartum, postpartum-neonatal period and appropriate use of emergent and comprehensive medical services as necessary.

Evidence-based maternity care by birth attendants trained in physiological (non-interventive) management achieved “maximal results with minimal interventions” by a wide margin. This cost-effective care had equally good outcomes, the fewest medical and surgical procedures and least expense to the healthcare system.

To paraphrase the popular African saying, it takes a village of skilled and knowledgeable people to support the safe passage of mother and baby thru pregnancy and birth.

 

Part 1 (of 2)

Prologue:

How 19th-century obstetrical thinking still dominates childbirth practices in the United States
Why understanding the history of obstetrics is the first step in creating a 21st-century maternity care system for healthy women based on the principles of physiological support for normal childbirth
The Basic Problem: Misplaced fear, lack of trust, inadequate or incorrect information about normal childbirth

There has been a wide-spread misunderstanding about the actual dangers of normal childbirth in the United States for more than a century. The lay public and American medical profession often see dangers where there are none, while at the same time they also fail to appreciate the substantial dangers introduced by the routine medicalization of normal childbirth in healthy childbearing women with normal pregnancies.

Historical Circumstances ~ Part One: Obstetrics in America

The historical practice of obstetrics in late 19th century America was part of the general (i.e. non-surgical) practice of medicine as provided general practitioners (GPs). If the patient of a GP needed an operative delivery, he was forced to call on the services of a gynecological surgeon. This often caused delays and other practical problems; it also was frequently accompanied by a difference of medical opinion between these two doctors that caused contention and even hard feelings.

To eliminate these professional problems and advance this field of medicine, the surgical specialty of gynecology combined with the medical discipline of obstetrics in the early 1900s to form the surgical specialty known today as “obstetrics and gynecology”. As surgical specialists, the role of Ob-Gyn doctors has always been to treat life-threatening complications of childbearing by using various medical and surgical interventions developed specifically for that purpose.

Because these early 20th-century obstetricians were only called in emergencies, they experienced childbirth as fought with danger. Just as police officers who deal with criminals all day-every day tend to see lawlessness everywhere look, so obstetricians tended to see normal childbirth thru a lens that focused tightly on its dangers. Given the life-threatening complications that doctors saw with such disturbing frequency in the early 1900s — long before birth control was available to married women and 40 years before the development of antibiotics, safer anesthetics and blood transfusions — it was logical for doctors to assume that childbirth itself was fundamentally defective and dangerous.

In fact, early 20th-century textbooks identified normal childbirth as a pathological aspect of female reproductive biology. Dr. Joseph DeLee, a famous obstetrician of that era and his contemporaries, erroneously concluded that normal childbirth was actually a cruel trick of Mother Nature, who had crafted a sacrificial process for human females similar to that of salmon that always die after spawning. Quite naturally, these assumptions applied to all childbearing women, included the great majority of healthy women with normal pregnancies.

Dr. DeLee and his contemporaries saw all childbirth services as a fight btw a vicious Mother Nature, who historically did her best to kill each and every new mother, and the obstetrical profession. In this perspective, the only way to stop the biologically-programed sacrifice of new mothers was the early and frequent use of obstetrical interventions. Each and every time a doctor was called a so-called ‘normal’ labor and birth, he was grateful for the weapons lent to him by modern medicine — forceps to pull the baby out quickly before the mother died, and in dire situations, a scalpel to perform an emergency Cesarean (itself a very dangerous intervention during the pre-antibiotic era).

Under such circumstances, it was also logical to assume that the same medical and surgical interventions that so successfully treated obstetrical complications would, if used prophylactically, correct for all Mother Nature’s obvious mistakes.

Obstetrical care became the default standard for all childbirth services in the US specifically because it routinely medicalized all phases of normal childbirth in all childbearing women. It is a process designed to get the results it produces.

It is a process designed to get the results it produces.

The Problem ~ Part two ~ Physiologic Childbirth practices & midwives

Because obstetricians saw labor and birth as a pending emergency, the idea of physiological care as provided by midwives and country doctors was seen as so inadequate and old-fashioned that it constituted substandard or negligent in the new world of scientific medicine.

This early 20th-century bias against physiologic childbirth was institutionalized in medical school curriculums, as successive generations of medical students were faithfully taught that normal childbirth was a pathological form of female physiology. This gave rise to a comment still used today that characterizes “Mother Nature” as a “bad obstetrician“, therefore equating the natural biology of childbirth as undependable and potentially dangerous.

As a result, the aggressive or “preemptive” use of obstetrical interventions has been seen as the superior model of care for the last century. As noted earlier, obstetrics became the standard form of maternity care specifically because it routinely medicalized all phases of normal pregnancy and childbirth in all childbearing women. A fundamental misunderstanding and disdain for the appropriate use of physiologic childbirth practices dominated the practice of obstetrics throughout the 20th century and it continues to define the obstetrical perspective in the 21st century.

When obstetrical medicine is used to diagnose and treat abnormal conditions and the complications of childbearing, the results are unprecedented in their effectiveness, and truly are ‘miracles of modern medicine’. It goes without saying that we are all grateful for the ability of obstetricians, in conjunctions with other modern medical services, to save lives and relieve suffering of childbearing women with serious complications.

This is indeed the ‘right use’ of obstetrics and we wouldn’t want it to be any other way.

But the surgical specialty of obstetrics and gynecology went way beyond this appropriate role. They genuinely believed that the prophylactic use of obstetrical interventions could and would eliminate, or at least drastically reduce, all serious complications of childbearing. Unfortunately these same obstetrical interventions and surgical procedures, when used pre-emptively as a routine aspect of standard care for healthy childbearing women with normal pregnancies, introduce unnecessary risk and are associated with a long list of iatrogenic complications.

In military terms, this is described as “right tactic, wrong terrain” — that is, the idea has merit but it is being applied in the wrong circumstances. Routinely using obstetrical intervention as the standard of care for healthy women is a ‘wrong use’ of obstetrics. In other words, the idea itself has great value, but is being applied in the wrong circumstances. In this case, the universal application of these interventions to healthy women can also represent another military phenomenon known as “mission creep“.

But historically the obstetrical profession did not see any problem with its medicalizing of normal childbirth. From its perspective, it was clearly able to outsmart “Mother Nature”; the only thing standing between them and their ability to make these life-saving services universally to all childbearing women was the midwifery profession. In obstetrical terms, this was known as “the midwife problem”, which was soon attacked by its best and brightest minds. By 1910 these influential obstetricians began to formally lobby state legislatures all across the country for obstetrics to be defined as the universal standard of care for all childbirth services under all circumstances and for the lawful practice of midwifery to be ‘phased out’ as quickly and quietly as possible.

To help sway public opinion to their side, leaders in the obstetrical profession implemented a public relations campaign in newspapers, radio programs and women’s magazines. It enthusiastically promoted obstetrics as the new, better, smarter — in fact the ONLY way — for a “modern woman” to safely have a baby. This was also accompanied by a barrage of articles portraying midwives as ignorant and dirty and their care as outdated and dangerous. Many of these articles urged women not to choose a midwife and husbands not to allow their wives be attended at home by a midwife.

The same uncritical acceptance of the same unscientific premises that began in 1910 (the notion that physiological childbirth practices are dangerous) has continued unabated and unchanged for a hundred years. The nature of this problem “right tactic, wrong terrain” is with us to today as the contemporary problems and iatrogenic-nosocomial complications of an obstetrically-based maternity system routinely using obstetrical interventions on healthy women with normal pregnancies.

What really is the problem?

What kills childbearing women and their unborn/newborn babies and causes a life-time of disability and social ostracism has been the same throughout all history periods and all over the world.

The five most important dangers of childbearing

The five most important dangers of childbearing have far more to do with contemporary social and political barriers that reflect pre-scientific periods of history, geography, economics, social prejudice, and personal mental problems than the basic biological characteristics of normal childbirth.

The historic danger of childbearing was to live before the development of scientific medicine. The geographical danger of childbearing is to live in parts of the world that don’t have a functional (scientifically-based and effective) healthcare system. The economic danger of childbearing is to live in a country with a profit-based medical system that is so expensive the family can’t afford necessary care. The social danger of childbearing is to belong to an ethnic or religious culture that rejects the use of modern medicine. The personal danger of childbirth is to be a pregnant woman unlucky enough to have mental or emotional problem that causes her to reject life-preserving maternity services.

While the biological dangers of childbirth for mothers and their unborn/newborn babies are real, risk of death and long-term disabilities become vanishingly small when childbearing women have access to a healthcare system that provides effective maternity services and necessary medical services.

Currently, the most dangerous place in the world to be a childbearing woman has a MMR of 2,000 per 100K live births – that is one death for every 50 births. If you have 7 or more children, your chances of dying in childbirth are as high as 1 out of 8.

In a 21st century world, 99 times out of a hundred the problem is not the biology of pregnancy and childbirth but the inability, for whatever reason, to access to life-sparing maternity care and perinatal services.

Whether that is because a woman can’t afford care, it geographically unavailable to her, or prejudiced individuals deny care to people of your color or ethnicity, your husband who won’t ‘allow’ you to use medical services under any circumstances – childbearing is a potentially deadly condition that results in tragic deaths of mothers and babies because normal childbearing was isolated from the modern maternity care process and appropriate use of elective and emergent medical services when needed.

So the 4-part answer is so simple it may shock or even anger the reader:

it is lack of access to a modern (i.e. scientific and effective) healthcare system that provides maternity care to all childbearing women (regardless of ethnicity or ability to pay) by that is:

  • Accessible, affordable and acceptable to the women it services
  • provided primarily by non-obstetricians (midwives and GPs)
  • includes referral to scientifically appropriate medical services as needed
  • these medical, obstetrical & perinatal services are provided in a safe, timely and effective manner

This universal safety net includes initial and on-going screening for abnormal conditions and complications (with appropriate referral to medical services), routine prenatal care, a train birth attendant (midwife or physician) present throughout active labor, birth and immediate postpartum-neonatal period, with follow-up care routinely provided to new mother and baby and appropriate use of medical services any time a complication develops or the mother requests medical care.

What is vitally important – the core issue — is that modern and comprehensive healthcare systems exist, that childbearing women have access to it (i.e. no racial, ethnic discrimination and family is able to pay for needed services) and the childbearing family is willing to use such services (i.e. no religious beliefs that preclude medical care or introduce gender-related barriers to receiving such care).

Concepts of “safety” in regard to maternity care must factor in its acceptability to childbearing families. Relative to regulations about the practice of California licensed midwifery, any regulation that leaves pregnant women without the legal options of midwifery care and thus forces them into highly-medicalized but unwanted hospital obstetrics or lay mfry or unattended labor and birth, is functionally a denial of services that introduces totally unnecessary risks for both mother and baby. Many of these women have very real, very respectable reasons for declining hospital-based obstetrical care as a ‘risk-reduction strategy that

Many of these women have very real, very respectable reasons for declining hospital-based obstetrical care as a ‘risk-reduction strategy that unfortunately does NOT in their particular case actually reduce the risk to them, or it exchanges one set of risks (ones acceptable to the family) for a set that are may actually higher (ex. unwanted repeat Cesarean) and/or otherwise unacceptable to that particular family. This is particular an issue for women with PTSD as a result of prior physical or sexual abuse or a previous traumatic birth experience.

Any law or regulation that creates an ipso-facto denial of services represents a one-dimental definition of ‘safety’. Whether this happens as a result of politics or genuine concern, any law that prevents childbearing women from receiving the care they need is a bad law. Time for a little Nancy Reagan “Just say No”.

Part 2: Five Model, Five Perspectives, Five Insights on Safety vs Danger in normal childbirth in the 21st century

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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. 

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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.  

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