California College of Midwives

 Dear Dr. Bishop ^O^

On behalf of California mothers and midwives, I want to welcome you to the Medical Board. We all look forward to your moral leadership.

The March 29th ‘interested parties’ meeting for proposed mfry regulations #1 & 2 was attended by approximately 140 people – consumers, LMs and CNMs and lobbyists for organized medicine. Attendance was so great that the MBC staff had to hold the meeting in the facility’s courtroom and still an overflow room with speakers was required. Oddly, lobbyists from CAPLI, the big three med-mal carriers, and the Trial Lawyers Association did not attend.

The March 29th event was audio taped by the Board and a CD of it is available as upon request. The meeting was also video taped by a member of the public, so the presentations by the staff and testimony of each participants is posted on the California Licensed Midwives YouTube channel and Facebook page. However, if you scroll to the bottom of this post, you can watch a segment of the testimony as provided by two obstetricians, Dr Ruth Haskins (former member of the Mfry Advisory Council) and Dr. Stuart Fischbein, who works  with licensed midwives in the LA area.

I have included easy access to the Feb 3rd Quarterly Board meeting webcast relative to the physician discussion on proposed mfry regulations. Due to length limitations on YouTube, the first half of the Feb 3rd discussion is posted at the bottom of part 2 of this ‘welcome letter” and last half of the Board’s webcast  is included at the bottom of the final part (3) of this communication.

Regulatory issues relative to California licensed midwives: 

You strike me as a rational, ‘no-nonsense’ person. With ample access to background materials and the specific facts of this situation, I believe you will see that the best interest of the Medical Board as a respected state agency, the professional interests of obstetricians in our state, the safety and practical interests of childbearing women and their families, and the legal interests of California LMs all lie in supporting the two proposed regulations discussed at the February 3rd Board meeting.

The reason is simple — it eliminates the stumbling block of unnecessary and artificially-injected vicarious liability.

Your account of the “total disaster with a midwife” at the February 3rd Board meeting aptly illustrated the total failure of the supervisory clause and the critical need to approve the proposed regulation #1. Unfortunately, the present situation sets up an “agent-agency” relationship that results in MD liability.

However, if vicarious liability were eliminated via a ‘collaborative’ relationship  (instead of one whose major feature is physician liability), it would also eliminate the need for midwives who provide care in a large city to drive a laboring women 60 miles way to a smaller town in order to have access to the one and only obstetrician in a 120 mile radius who is either willing or able to provide medical care when it becomes necessary.

This regulatory change is the only effective way to provide childbearing women access to necessary obstetrical services without having to transport to a hospital 60 miles away. Cooperative relationships between LMs and MDs are better for babies, the childbearing family AND all the professionals and hospital staff that otherwise may quite unfairly find themselves in the middle of a malpractice nightmare.

Even though the care of LMs is a non-medical discipline, traditional midwifery is still very much a part of the mainstream healthcare system. As a profession regulated by the MBC for the last 19 years, licensed midwives will continue to function in a manner that is respectful of both the letter and spirit of the law. 

You may or may not be familiar with a 1999 ruling by the Office of Administrative Law that provides a legal frame work for LMs to practice lawfully in spite of the insurmountable barriers of physician supervision as currently interpreted.

Supervision ~ legally-flawed & unworkable

A full examination of the physician supervision clause will follow in part II of this 5-part communications. But its impossible to discuss the issue at all without first identifying the major reasons that it is so profoundly  unsuccessful.

The California Medical Association insisted that the LMPA mandate a supervisory relationship between each licensed midwife and a physician who has obstetrical privileges at a local hospital. However, this same provision of the law does not stipulate that California licensed physicians provide the required supervision. This mis-matched arrangement requiring midwives to be supervised by obstetricians while not requiring obstetrician to supervise midwives, is obviously a constitutional issue. In addition, there are many practical problems.

One significant issue is the insistence by the obstetrical profession and med-mal carriers that physician supervision specifically be interpreted as a relationship of agency, in which the LM legally becomes the ‘agent’ of the MD. This places the physician-midwife relationship under a legal theory known as “captain-of-the-ship/borrowed-servant“.

As the  ‘captain of the ship’, the obstetrician becomes responsible for the torts of any supervised midwife and the LM legally becomes the MD’s agent or ‘borrowed servant’. It is this definition — one specifically chosen and promoted by ACOG and CAPLI — and not the ‘plain-letter’ language of the LMPA that creates the insurmountable burden of vicarious liability on any physician who volunteers to takes on this unpaid role.

Another issue is the volunteer nature of this position on the part of the physician. The supervising MD is being asked to provide his or her most valuable professional asset — expertise in the field of obstetrics — for free, while simultaneously taking on the burden of vicarious liability and any addition premium his or her med-mal carrier may impose.

Legal & Legislative Work-around

Fortunately, the 1999 by ruling OAL Judge Roman and a legislative amendment to the LMPA passed in 2000 (SB 1479~Figueroa) provided relief to this otherwise impossible situation. When California licensed midwives follow the specific criteria identified by Judge Roman’s ruling and subsequently enacted in SB 1479, the current practice of LMs, with or without supervision, is lawful.

This means each woman who is anticipating a PHB (planned home birth) under the care of an LMs has formally identified specific arrangements for timely medical evaluation and/or treatment during the ante-, intra-, and post-partum/neonatal period, including both elective and emergent hospital transfer.

In some cases this results in a de facto collaborative relationship between the physician and the licensed midwife. In others, the mother-to-be identifies Kaiser or another HMO as the provider of choice, or she has an informal arrangement with a midwife/PHB-friendly OB in the community. The next most frequently identified medical interface chosen by childbearing women is concurrent care with an obstetricians. This situation is best described as  ‘don’t ask-don’t tell’, as med-mal policies don’t permit obstetricians to knowingly provide concurrent care to women who are also seeing a midwife or planning a home birth.

When none of the above options are available, the midwife and mother together identify a hospital in their geographical area that has an obstetrical residency program and/or is a regional tertiary care facility. Irrespective of the particulars, no mfry client ever goes without a predetermined medical interface plan. As required by law, this is formally documented,  signed by both LM and client, and becomes part of the patient’s chart. 

A Record to be Proud of: 19 years of MBC-regulated midwifery

In the 19 years since the LMPA was passed, and in spite of policies of non-cooperation by many in the obstetrical community, California midwives have been able to provide safe, effective, and compassionate care to approximately 100,000 mothers and babies.

While the national average for non-operative delivery is only 54%, the spontaneous vaginal birth rate for women attended by California licensed midwives is 91.7% (i.e., no C-section, forceps or vacuum extraction). These favorable statistics include all intra-partum transfers of women who subsequent delivered in hospital. The neonatal mortality rate for LMs is 0.89 per 1,000 (again including all transfers of care), while the national average for a demographically non-ethnic caucasian population who deliver at term is 0.79 per 1,000. 

Examples of the effectiveness of non-medical midwifery care for healthy women can also be seen in the very low prematurity rate for California licensed midwives. While the annual prematurity rate in the US is a very costly 13%, premature labors in women seeking maternity care from LMs is under 1%. This low prematurity rate associated with LM care has a substantial economic advantage, with only 84 cases of pre-term labor as documented by the Licensed Midwifery Annual Report (LMAR) over the last 4 years, instead of the statistically-predicted 833 for that same timeframe.

The California Medicaid program saved hundreds of thousands of dollars by having 749 fewer babies spend weeks or months in the NICU. A healthy childhood for the 749 babies who went to term instead of going to the NICU as a premie also reduced long-term developmental problems and learning disabilities frequently seen in premature babies, and so saved even more money for society and heartache for families.

According to the latest data on Cesarean delivery, the safest maternal-infant outcomes are associated with an incidence of C-sections between 5% and 10%. Our current national average is a 32.8% Cesarean rate. However, outcome statistics as documented in the LMAR for the last 4 years is a Cesarean rate for California LMs between 7.7% and 8.3% — the middle range of this optimal zone.

The dramatically reduced Cesarean surgery rates among LM clients also prevents substantial operative morbidity, days of hospitalization, and delayed and downstream complications — all of which results in a dramatic reduction in the healthcare costs. 

Continue to Part 2 ~ 

An in-depth examination of supervision; the historical relationship btw MDs and non-physician practitioners

Webcast of two obstetricians (Dr. Ruth Haskins & Stuart Fischbein) at March 29th Interested Parties meeting.[youtube]http://www.youtube.com/watch?v=9yzpnSCuzXo&feature=plcp[/youtube]

From the Journal of Family Practice Dec 2010

It’s time to collaborate—not compete—with NPs

Jeff Susman, MD  Editor-in-Chief jfp@neoucom.edu

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs. Why do I call for such a fundamental change in policy? First, because it’s the reality. In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice.

Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010.

Among the IOM’s conclusions:

• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training. Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.)

Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care. Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition. As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisioning the future of health care.

The Journal of Family Practice ©2010 Quadrant HealthCom

Tags: physician supervision, physiological CB practice vs. obstetrics, ACOG ruling ethical to perform medically unnecessary Cesarean surgery, Ob-GynNews

There is much disagreement about the appropriate relationship between physicians and midwives. At the core of the question about the modern role of midwifery is yet another question — what is the right relationship between “modern” medicine and “modern” childbearing? Has the obstetrical knowledge of the 20th century fundamentally changed the nature of childbirth (which is a natural biological act) the same way medical science fundamentally changed the course of human illness, disease, deformity and accidental injury (all forms of pathology)?

This controversy has nothing to do with the appropriate use of obstetrical medicine to treat the 30% of pregnant women who develop complications, about which there is a widespread agreement. Rather the question concerns using these same forms of medical interventions routinely or “prophylactically” (the ‘pre-emptive strike’) on the 70% of healthy women with normal pregnancies.

In addition to society’s general lack of confidence in the normal biology of childbearing, there is even greater anxiety about place-of-birth, which includes an automatic rejection of Planned Home Birth (PHB). The most familiar perspective about midwifery and PHB assumes that licensed midwives are practicing some aspect of obstetrical medicine without an obstetrical education or appropriate access to the emergency medical services that we assume are instantly available in hospitals – a professional staff, drugs and surgery, etc.

Were that grim perspective true, childbirth services in a domiciliary setting would indeed be a risky undertaking. This would result in a greatly increased perinatal and maternal mortality and morbidity, which would be reflected birth and death certificates, and research which contrasts PHB with Hospital-Based Obstetrics (HBO). In fact, the consensus of the scientific literature reveals the exact opposite – its supports PHB under the care a professional attendant. The principles of physiology, which underpin the midwifery model, do not belong to midwives but to human biology, to be used widely for the benefit of society. They can be used by all types of birth attendants, including physicians, and in all birth setting. While rare in the US, physiological management is the foremost standard of care for homes, hospitals and birth centers around the world.

Over the course of the 20^th century, there has been a devastating loss of ‘institutional memory’ by the medical profession. Beginning in 1910, physicians have moved farther and farther away from the principles of physiological management which were traditionally used to provide care to healthy women. As a nursing student in the early 1960s, the form of childbirth practiced in our hospital was already redefined as a surgical procedure. Women gave birth under general anesthesia with the routine assistance episiotomy and outlet forceps. However, as a student nurse in 1961, just prior to court-ordered desegregation in the South, I got to closely observe and directly participate in two entirely different, racially segregated systems — side by side, in the same hospital, at the same time, with the same staff and the same type of patients. These two management styles and the outcomes for each were different as day and night, but not in the way you might expect. More was not better.

However, as a student nurse in 1961, just prior to court-ordered desegregation in the South, I got to closely observe and directly participate in two entirely different, racially segregated systems — side by side, in the same hospital, at the same time, with the same staff and the same type of patients. These two management styles and the outcomes for each were different as day and night, but not in the way you might expect. More was not better.

Orange Memorial Hospital (now Orlando Regional) in Orlando, Florida provided a naturally-occurring, one-of-a-kind scientific study, contrasting the two styles of maternity care – a profoundly interventionist model, characterized as “knock’em out, drag’em out” obstetrics, versus a lazier-fair system that resulted in, ipso facto, classic physiologically-managed maternity care of the type routinely provided by midwives like myself. It all depended on whether the laboring woman was black or white.

White mothers were admitted to the whites-only 5^th floor L&D unit, where they were isolated from their family, immobilized in bed, heavily narcotized, given general anesthesia, a “generous” episiotomy was routinely performed, outlet forceps used to “lift” the baby out. Their babies routinely required resuscitation (about 5% could not be revived). This was followed by the manual removal of the placenta and lots and lots of sutures and what our OB doctors liked to call “the husband stitch”. Then these still anesthetized new moms were rolled by stretcher to a recovery room where they retched and gagged their way back to consciousness over the course of several hours.

The only upbeat note in this bleak description is that obstetricians of that day were still expected to manage breech or twin deliveries vaginally, which they did skillfully and, given the amount of drugs that we had given to these mothers, with remarkably good outcomes.

Black mothers were denied access to the white labor rooms in our racially segregated hospital and as a consequence, ‘denied’ all these lovely, potentially injurious interventions. Racially-motivated institutional neglect (luckily) meant our black moms had physiologically managed labors and deliveries and much better outcomes than the ‘other’ cohort. In 1961, our black moms were not drugged or restricted to bed, no anesthesia was offered or used, no episiotomy, no forceps, no manual removal of the placenta, no stitches and no babies that were too undrugged to breathe on their own. I’ve always considered this to be a bit of poetic justice.

As a staff nurse working in the labor and delivery room for the next 10 years, I also participated in the integration of our obstetrical system in the early 1970s. Unfortunately, court-ordered “equal treatment” had unintended consequences, in that we just imposed injurious interventions on both our black and while moms.

Since the medical malpractice crisis of 1976, physiological principles of childbirth have been virtually eliminated from the medical school curriculum. Today, the greatest realistic danger for healthy women who are well-fed, well-housed, well-educated, and well-cared for during pregnancy, is over-treatment and the cascade of complications associated with routine interventions such as induction or augmentation of labor, narcotic pain medications, anesthesia, episiotomy, forceps, vacuum extraction, Cesarean surgery or manual removal of the placenta.

The medicalization of normal labor triggers a chain of inevitability that starts with the ‘domino-effect’. This is a string of unintended consequences consistently triggered by routine interventions. It makes childbirth progressively more complex, even if it does not result in complications. Unfortunately, for a significant number of labors, the mounting complexities eventually make injurious interventions a necessity.

In far too many instances, this progresses to serious complications that are iatrogenic in origin. However, we are all being lead to believe that the injuries to mothers or babies associated with aggressive and routine use of obstetrical interventions are the result of the ‘defective’ biology of childbearing. This seems to be a modern day version of Freud’s claim that “biology is destiny”, at least when it comes to gender. Mothers and/or normal birth gets blamed, instead of questioning the over-use of interventions which actually triggered the cascade of complications that resulted in the final adverse event.

The childbearing pelvis – that is, the internal bones that the baby must pass through — normally creates a hollow space shaped like a lower-case letter “j”. Most people erroneously think of the birth canal as a straight chute (lower-case ‘l’), going straight down thru the lower half of the mother’s body. In other words, if the mother was lying down and you were watching from the side, her baby would pass through the pelvis and out of her body the same way a train comes out of a tunnel – a straight cylindrical object passing thru a straight cylindrical container.

But this is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side as she labors and gives birth while still in an upright posture. If you had x-ray vision, you would see that the long stem of the ‘j’ tracks with the mother’s lower spine and the curved foot of the letter bends forward to track with the lower half of the birth canal.

What this means is the pelvic outlet — last 1/3 of the journey – bends at a 60-degree angle (technically known as the Curve of Carus), which requires that the baby to go around a corner and emerge into the world going forward (into its mother’s arms!) instead of down (where in the ancient world it would be hard to reach by the mother and might be injured as it fell to the floor). Not doubt this “frontal delivery” is an important survival characteristic, as for 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for catching her own baby.

 

Were you to look down into the pelvis from the top, you would notice that the big triangle-shaped bone of the lower spine — the sacrum and coccyx — encroach forward into the pelvic outlet about an inch or so. In this regard, the pelvis is like a hollow bowl with smooth walls on three sides but the fourth side is bent in, making it impossible for anything that is the same size and shape as its circumference to pass through.

However, in the second stage of labor, after the baby is squeezed out of the uterus thru the cervix and starts its trek down into the birth canal, you would see something remarkable happen. In pregnancy, the sacrum and coccyx are able to move somewhat and are actually pressed back out of the way by the baby’s head as it descends lower and gets closer and closer to being born. The hormones of pregnancy also make the cartilage that holds the two sides of the pubic bone together become very elastic. Thus the pelvis can stretch and become wider side-to-side, which can give the baby an extra 1-2 centimeters of room to negotiate its passage into the world.

Of course, this nifty trick ONLY works if the mother is standing, squatting or is in some other position that makes ‘right use’ of gravity and allows her sacrum to move back out of the way (similar to the way a pet door is pressed open by the dog or cat as it passes through). However, if the mother is bearing her own weight on her lower back, such as lying down with her legs held up in stirrups, the sacrum cannot move out of the way, and sometimes the trap door gets stuck in the closed position. When a woman tries to give birth lying down, not only must gravity be defined in order to push the baby uphill and around a corner, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis by as much as a third.

If the baby is small or the mother’s pelvis is big, the forces of labor and extra effort on her part can overcome this impediment. However, for a mother who lying down, the baby will still have to be pushed uphill and will emerge in an upward angle (towards the ceiling). This is obviously a lot harder and may require the use of forceps or vacuum if the mother has had anesthesia. Unfortunately, if the reverse is true (a relatively big baby and/or small pelvis) the baby can get stuck – the ‘obstructed labor’ of Old World fame but with a New World reason. In modern life, this would require a forceps delivery or a Cesarean.

In the ancient world or for women in poor countries without access to obstetrical services, cephlo-pelvic dystocia (CPD) eventually results in the death of the baby and may cause the mother to develop a fistula between her bladder or rectum or other debilitating forms of incontinence due to obstructed labor or associated with the use of episiotomy and forceps. It should be noted however, that CPD caused by positioning the mother on her back or other “wrong uses of gravity” in modern societies and the damage it may cause to the baby or the mother’s pelvic floor, are iatrogenic in origin and therefore preventable complications.

This out-of-control situation has the US tittering on the brink of a precipice in the 21^st century, with a 50% Cesarean section rate predicted by the obstetrical profession. Some vocal obstetricians are promoting Cesarean section as the new, 21^st century standard of care for all childbirth. Obstetricians consider this to be good lawyer ‘insurance’—that is, a hedge against malpractice litigation, the idea being that you can’t sue a doctor who did a C-section before the mother was even in labor.

In 2000 Dr. Ben Harer, who was president of ACOG at the time, appeared on the Good Morning American show, promoting the idea that vaginal birth was dangerous to mothers and babies and the operative risks of C-section were minimal and actually “no greater” the normal birth over the long run. This statement is not supported by facts.

However, in 2003 ACOG’s ethics committee ruled that it was ‘ethical’ for obstetricians to perform medically unnecessary Cesareans, claiming that no good data was available to determine the relative safety of normal birth versus Cesarean section. After this decision was announced by ACOG,

After this decision was announced by ACOG, Dr. Harer was interview by the Washington Post. In an article, Dr. Harer fully supported the idea that it was ethical for obstetricians to perform medically-unnecessary Cesarean surgery, saying:

“I think it’s a step to where we’re going. And my guess is that as increasing evidence comes out, it will probably become a more accepted procedure… Before this statement, it was gray area. This clarifies it and gives it some permissibility.”

The Post went on to report that Dr. Harer had “triggered a furor when he was president of the organization by arguing that women should have the option of a Caesarean.”

National Institute of Health (NIH) (2006) public conference on the ‘maternal request’ Cesarean

March 27-29^th of this year (2006), the National Institute of Health (NIH) held a public conference on the ‘maternal request’ Cesarean. Many consumers and midwives attended. Interestingly, the conference officials released a draft report at

Interestingly, the conference officials released a draft report of its finding at 5 pm on the dot on the last day. There was no way they would possibly have integrated input of those who attended and compiled this report while the conference was underway. As a result, we must assume the contents of the NIH report on was compiled prior to the event.

In spite of massive evidence to the contrary, the NIH report concluded that there was no evidence that delivery by electively-planned Cesarean was any more risky than planned vaginal birth.

This reflects two highly disturbing things – first a biased interpretation of the scientific literature that favors the obstetrical profession at the expense of the patient/consumer and the fact that a century of ever-increasing medicalization of normal childbirth (exacerbated by the 1976 malpractice crisis) has succeeded in protecting doctors from litigation by making vaginal birth every bit as risky as major abdominal surgery. And the ugly stepsister of this situation is a uniform lack of any true informed consent on the part of patients who dutifully follow this disturbing advice.

Headline  on NIH’s report: “Elective Cesarean: Honor Her Choice”.

On April 15^th, 2006 Ob.Gyn.News (Volume 41, Issue 8) summed up the NIH’s report with a headline that read: “Elective Cesarean: Honor Her Choice”. Here’s the little slip twist cup and lip conveniently ignored by ACOG and NIH.

Unique ‘route of delivery’ risks of cesarean includes 33 well-known complications (including a 13-fold increase in emergency hysterectomies) compared to only 4 specific ‘route of delivery ‘ risks for normal vaginal birth [Maternity Center Association of NYC’s systemic review “What every pregnant woman needs to know about Cesarean Section” at www.maternityWise,org].

Childbearing women who are delivered by Cesarean section are two to four times more likely to die from the intra-operative, post-operative, delayed or downstream complications of Cesarean surgery than from normal vaginal birth (including the most complicated vaginal delivery). More than a dozen operative and post-op complications for the mother are associated with Cesarean surgery, including maternal death, maternal brain damage, anesthetic accidents, drug reactions, infection, accidental surgical injury, hemorrhage, emergency hysterectomy, blood clots in the lungs, the need to be admitted to ICU, the need to be on life support and inability to breastfeed.

Potentially-lethal complications and protracted difficulties extend into the postpartum, post-cesarean reproduction, post-cesarean pregnancies and post-cesarean labors. Reproduction complications include secondary infertility, miscarriage and tubal pregnancy necessitating the surgical removal of a fallopian tube. Downstream complications in future pregnancies include placental abruption, placenta previa, placenta percreta, uterine rupture, and maternal death or permanent neurologically impairment.

Risks to babies include accidental premature delivery, surgical injury during the C-section, respiratory distress, increased rates of admission to NICU, chronic lung disease and increased rates of both childhood and adult asthma. Risks to babies in subsequent pregnancies include placenta abruption/stillbirth, death or permanent neurological disability (due to uterine rupture).

But don’t worry, tort law protects the obstetrician who performed the original (and often unnecessary) C-section from liability for any of these “post-OR” complications. Unless s/he accidentally stapled the patient’s ureter shut or some other egregious lack of surgical skill, the physician has purchased a life time of protection for him or herself by electing to perform a Cesarean section.

The information described above is easily accessible from reliable scientific sources readily available to the average obstetrician. Relative to non-urgent and medically unnecessary Cesarean section, this body of knowledge constitutes true informed consent. I quote the California Medical Association’s Document # 0415 – Informed Consent, Jan 2001: “..a physician must disclose all information which is ‘material to the patient’s decision of whether to proceed” (that is) “that information which the physician knows or should know and would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended procedure. ….. This includes the risks, complications, expected benefits of the proposed treatment (including likelihood of success) and any alternative to the procedure, including the alternative of no treatment and the relative risks and benefits of not having the procedure.”

The ‘Other’ Way

Everybody in society, even those who would never use a midwife or plan a home birth, would benefit from preserving and promoting physiological management. In a perfect system, medical educators would again learn and teach the principles of physiological management to medical students. Practicing physicians would utilize physiological management as the standard of care for healthy childbearing women. Hospital labor & delivery units would be primarily staffed by professional midwives working in tandem with obstetricians.

This would dramatically reduce rate of injurious medical interventions and the cost of maternity care while increasing good outcomes and satisfaction of families served. Should the US ever suffer a catastrophic event such as dirty bomb, avian pandemic or effects regional storms such as Katrina, it will be very helpful to have a system of physiologically-based maternity care that does not have to depend on “surgery-intensive” methods for normal childbirth in healthy women.

By making maternity care in all settings equally safe and equally satisfactory, families would not be forced to submit to forms of care that are not appropriate for their needs. This would also permit American women to use a physiological form of care referred to in Holland as the “relocated home birth”. A ‘relocated home birth’ is a planned birth delivery, in which Dutch midwives accompany their patients to the hospital after active labor has begun. The professional midwife continues to personally provide physiologically-based care in a “low tech” homey environment. Should obstetrical services become necessary, they have immediate access to them. Surely ACOG’s most enlightened response to PHB would be appropriate changes in planned hospital birth, so that it better addressed the needs and desires of healthy women with normal pregnancies who do not wish to use drugs to accelerate labor or pain relief or anesthesia for delivery.

Community Midwives ~ Do More With Less?

Let me begin by addressing the question of how community midwives, who are not trained in obstetrics and do not have recourse to the use of drugs, instruments or surgery in domiciliary setting, can possibly have ‘good outcomes’ that equal or exceed hospital-based obstetrics (HBO). It does seem to defy logic, when you consider that current intervention rates for healthy women (according to the CDC) include12% forceps /vacuum extractions, 23% inductions, 29% C-sections and a 33% episiotomy rate. People see all these complications in hospital births, and based on that, they think anyone would be crazy not to be in a hospital, given what seems to them to be a very strong likelihood of something going horribly wrong.

Logically, this perceived level of complexity would argue that a minimum of 50% of women choosing PHB would suffer severely as a result of unmet medical or surgical needs, since LMs are not legally permitted to practice medicine or surgery. These mothers would either require intrapartum transfers (resulting in a 50% hospitalization rate for PHB clients) OR uncorrected intrapartum pathologies would result in preventable deaths or disabilities more than half the time. I can assure you that midwives are not burying dead bodies in anyone’s backyard. To cover up such a crime, we would also have to ‘dispense’ with all the rest of the family, the relatives, neighbors and anyone else who knew about the planned home birth. Obviously, there must be some more likely explanation.

The ‘other’ explanation is that PHB actually is as safe (or safer) than HBO. The consensus of the scientific literature consistently identifies perinatal mortality rate to be virtually identical for both groups (approximately 2 per 1,000 for both PHB and HBO), with a dramatically reduced rate of obstetrical interventions — three to ten times less for the PHB cohort. The most recent study contrasting home with

The most recent study contrasting home with hospital was published in the British Medical Journal (June 2005). For the PHB cohort, it identified a perinatal rate of 2 per 1,000 and a Cesarean rate was under 4 percent for women who began labor at home. The C-section rate for the HOB cohort was 24 percent.

It must be kept in mind that mortality and morbidity statistics are always attributed to the practice of midwifery, even if the patient was transferred to a physician or hospital or if the baby died some weeks later from SIDS or hospital-acquired infection.

A study published in 2002 also attributed unfavorable outcomes to PHB even if the woman risked out for PHB during last weeks pregnancy and was referred to a physician or if she delivered prematurely or precipitously before the midwife arrived.

So rest assured, the bias in statistical outcomes is significantly weighted in favor of obstetricians and HBO.

Physiological Process Explained

A little background about the midwifery model of care will help to explain how midwives do more with less and do it safely.

Midwifery as an organized body of knowledge preceded the modern discipline of medicine by more than 5,000 years. Midwifery principles recognized as effective and still valid in the 21st century were found among ancient Egyptian hieroglyphics dating back to 3,000 BC. The early discipline of midwifery was empirically-based and organized around meeting the practical needs of laboring women, which are primarily psychological, emotional, and social.

For healthy women in safe surroundings, childbirth was generally successful for both mother and baby. We know this is true because the human species has survived (and in fact thrived!) into the 21^st century. Anyone alive today is a direct genetic descendant of women who were successful at giving birth vaginally, without the need for drugs, forceps or cesarean surgery.

Midwifery is neither a practice of medicine or nursing but a separate discipline arising in response to the spontaneous biology of childbirth and the physical, psychological and social needs of childbearing women and their babies. This includes the ability to recognize and respond appropriately to complications. In contemporary times, the discipline of midwifery is both art and science. The art and science of modern midwifery is based on physiological management in combination with the best use of modern science. Today, these principles of physiological management are the scientific backbone or evidence-based model of maternity care used worldwide by midwives.

Medical dictionaries define ‘physiological’ as “..in accord with, or characteristic of the normal functioning of a living organism”.

This form of care is actually protective for both mothers and babies, lowering the rate of medical interventions. It also rates highest for maternal satisfaction. Nationally certified direct-entry midwives, using a physiologic process for PHB and timely transfers to HBO when indicated, reduced the episiotomy / operative delivery rate from approximately 72% to approximately 5%, with an identical or even slightly improved perinatal mortality rate. Physiologically-based midwifery care is efficacious — that is, both safe and cost effective.

Midwifery and obstetrics are at opposite ends of a continuum, spanning the most simple to the extremely complex. Their respective expertise overlaps in the middle of the spectrum but is not identical. Both benefit from the abilities of the other. The midwifery model of physiologic care has been repeatedly proven to provide the most appropriate caregivers for healthy women experiencing normal pregnancies.

But midwifery is more than an absence of obstetrical interventions. It is a positive model with specific methods for successfully addressing the most common problems that concern childbearing women and normal birth. The spontaneous nature of childbirth is best compared to a slow-motion sneeze – an internally triggered and coordinated process that has been fine-tuned by eons of biological evolution.

The art of midwifery depends on ‘patience with nature’, the right use of gravity, and a commitment not to disturb the natural process. It is a high-touch, low-tech, minimal-intervention model that includes continuity of care, the full-time presence of the caregiver through out active labor, one-on-one social and emotional support and non-drug methods of pain relief such as walking, one-on-one support, therapeutic touch and access to deep water tubs. Obstetrical intervention is reserved for complications and women who request medical help or anesthesia. This functional form of care for normal childbirth is supported by a consensus of the worldwide scientific literature.

Scientific Methods of Midwifery Revealed

The general principles of physiological management are divided into two basic strategies – a major and minor cord, so to speak. The primarily methods address the normal, supportive care of a laboring woman. It employs attitudes and behaviors such as a calm presence and the appropriate use of gravity. However, at some point in time, many labors contain variations or deviations from the average or straight forward trajectory of progress. So the second set of physiological strategies deals with physiologically-sound methods that permit a birth attendant (physician or midwife), to forward the action without initially having to employ medical or surgical interventions.

This is the place in the story that the lay public and medical community goes south – as neither can’t imagine that childbirth can be kept in the ‘normal’ category without the use of powerful drugs and medical devices. But midwifery is a distinct discipline with a unique knowledge base and set of skills that are not normally taught in medical school. Physiological principles are one end of the spectrum, while a through understanding of modern science of pelvic architecture, the biology of uterine activity and the principles of fetal monitoring is at the other end.

A uniquely modern skills learned by licensed midwives is a reliable method for monitoring fetal well-being without having to depend on continuous electronic fetal monitors. This technique, known as ‘intermittent auscultation’ (IA), uses criteria arrived at by medical science from 30 years of experience with EFM. IA is scientifically documented to be equally effective as EFM for low and moderate risk labors.

Using only a fetascope or doptone and wrist watch or clock with a sweep second hand and counting in a continuous series of five-second samplings over 60 seconds (12 or more sampling) immediately following a uterine contraction, it is possible to collect the same four crucial elements of information printed out so prettily on an EFM tracing.

These are the presence of a normal baseline (110-150), reassuring variability (5-25 bpm), intermittent accelerations (an amplitude of 15 bpm for a minimum of 15 seconds) and documenting the absence of pathological decelerations (a drop of 15+bpm over a period of 30seconds). An addition advantage of intermittent auscultation is that it does not suffer from one of the common technological glitches that bedevil EFM – the doubling of abnormally low heart rates and halving abnormally high numbers.

This kind of integrated knowledge permits midwives to monitor the well being of the baby while successfully addressing problems such as lack of progress which, if prolonged, can waste the mother and baby’s biological reserves, the type of painful labor that can retard progress or wear down the mother’s spirits, nausea that can result in labor delaying dehydration, lack of fetal decent during second stage which can result in fetal distress or the need for operative delivery and the reduction of perineal trauma.

Lack of Adequate Progress.

I’ll start with an all too frequent accompaniment of labor – a lack of adequate progress.

In the medical model this is routinely treated by starting an IV and administering Pitocin to ‘enhance’ or accelerate the uterine contraction pattern. This must be accompanied by EFM to continuously monitor the fetus, since some women are unexpectedly sensitive to Pitocin and can have tetonic contractions lasting from 2 to 10 minutes. This can result in such profound fetal distress as to necessitate a “crash” C-section. In order to manage this well-known complication of artificially stimulated labors, EFM is mandatory for any woman receiving Pitocin for labor stimulation. The combination of IV tubing and electronic fetal monitor leads effectively tethers the mother to the bed, making the strategies of physiological management virtually impossible t o use.

This can result in such profound fetal distress as to necessitate a “crash” C-section. In order to manage this well-known complication of artificially stimulated labors, EFM is mandatory for any woman receiving Pitocin for labor stimulation. The combination of IV tubing and electronic fetal monitor leads effectively tethers the mother to the bed, making the strategies of physiological management virtually impossible t o use.

This is particularly important when it comes to managing the normal pain of active labor, as the mother cannot easily change positions, nor can she walk around or get in the shower or a deep water tub. Once Pitocin-accelerated contraction become long, strong and close together, narcotics and/or epidural anesthesia usually becomes mandatory.

Unfortunately, pain-relieving drugs and anesthetics often slow down labor significantly, requiring the rate of Pitocin infusion to be repeatedly increased. The negative synergy of these drugs, each of which amplifies the unwanted side effects of the other, combined with the mother’s unfortunate immobility, often results in fetal distress or an inability to get the baby down far enough into the pelvis to permit the safe use of vacuum or forceps to assist a vaginal delivery. In those cases, a Cesarean will become necessary. For instance, the CS rate is 35% for first-time mothers who are induced before their cervix is ready for labor (.i.e., Bishop score of <6).

Unfortunately, pain-relieving drugs and anesthetics often slow down labor significantly, requiring the rate of Pitocin infusion to be repeatedly increased. The negative synergy of these drugs, each of which amplifies the unwanted side effects of the other, combined with the mother’s unfortunate immobility, often results in fetal distress or an inability to get the baby down far enough into the pelvis to permit the safe use of vacuum or forceps to assist a vaginal delivery. In those cases, a Cesarean will become necessary. For instance, the CS rate is 35% for first-time mothers who are induced before their cervix is ready for labor (.i.e., Bishop score of <6).

Now let’s look at this from the perspective of the licensed midwife providing care in a domiciliary setting and using the principle of physiological management. Knowledge of physiology teach that the right use of gravity stimulates labor, helps to dilate the cervix and helps the baby descend through the bony pelvis. Encouraging the mother to be upright and mobile not only helps labor process normally but also diminishes the mother’s perception of pain, perhaps by stimulating beta-endorphins, providing the comfort and distraction of movement and a greater sense of control.

Since the parents are in their own home, they are not affected by that subtle institutional sense of urgency reminiscent of a taxi waiting at the curb with the meter running. In the comfort and privacy of one’s own home, it’s more OK for the mother-to-be to take her time.

Assuming that fetal heart tones and other intrapartum parameters continue to be “reassuring”, the midwife providing care in a mother’s own home can encourage her to go for lengthy walks. The midwife may also suggest that the mother rest in her own bed or relax in the bathtub. This works very well for some mothers, letting them doze off for an hour or two.

After resting, other strategies for stimulating labor can be tried out one at a time. This includes upright and mobile position for the mother, walking, swaying or squatting, standing in the shower, nipple stimulation, acupuncture pressure points, a foot massage and conversations to determine if the mother is struggling with such a high level of fear or anxiety that it is retarding the progress of labor.

Last, certainly not least, is the ‘secret weapon’, what midwives refer to as the “H” word – the possibility of a hospital transfer. This is a conversation directed by the midwife, in which the mother is told the basic facts, such as:

“the last 2 (3, 4, 5, etc) hours, your contractions have not gotten any longer or stronger. They continue to be only 30 seconds long, so there is no change in your cervical dilatation over (X # of hours).”

The second half of that conversation asks the mother to decide:

“You and your baby are OK right now but how much longer are you willing to have painful uterine contraction without making any progress? One, two or three more hours?”

Then the mother and midwife must decide mutually what criteria will be used to determine “adequate progress” in the agreed upon time frame – for example: “at least one more centimeter of cervical dilation” or “uterine contractions at least 5 minutes or less and lasting for 55-65 seconds or longer” when she is rechecked in 2 hours.

This is a very useful exercise for the mother. It gives her a chance to determine for herself if she is really dedicated to making it work at home or would b e better served by going to the hospital. Sometimes she genuinely needs something that can only come from hospital-based obstetrics. I have many times seen laboring women who could not progress with the reassurance or feeling of safety. They just can’t surrender themselves with the total abandonment necessary until they are in the hospital. Mothers who have been 3 centimeters for 7 hours suddenly dilate to 7 during the20-minutee drive to the hospital and presto, change-o, they are pushing and delivered in another hour. Labor is often a zigzag course with plateaus along the way.

What ever it takes, a midwife’ job is to make it work for the mother and baby.

It is remarkable how often one or more of these tactics will forward the action and the mother will go on to have a progressive labor and give birth normally at home to a healthy baby. I’ve also had moms decide they just “couldn’t do it” and wanted to go to the hospital so to get ‘something for pain’. While everybody was packing up midwifery equipment and getting ready to leave for the hospital, the mother was calmly laying their, feeling at peace with her decision. Then suddenly she started to have spontaneous urges to push and sure enough, the baby was born shortly thereafter, at home. The only downside of this is the extra gray hairs that midwife acquires from packing up and then having to race to the car to bring it all back in.

Honestly though, we don’t mind.

Labor Pain

My next topic is labor pain, without which no labor progresses. As an aside, I have long believed that the painful nature of labor was proof that God’s gender is male, because only a guy would think up such a stupid system. Women would have the baby delivered by FedX at 10am Saturday morning, after the mother had a full night’s sleep. The baby would of course be cleaned up pretty and dressed in a cute outfit, with a sweet little bow in her hair. Personally, I’m going to complain big time about this when I get to Heaven.

Ok, now for reality. Labor hurts. Yes, I know that for a fact, as I’ve had three unmedicated labors and spontaneous vaginal births. Almost changed my mind each time. However, I think normal labor is best characterized by Winston Churchill’s comment about our democratic form of government – not a very good system, just better than any of the other alternatives. The obstetrical issue with labor pain is that every possible permutation of allopathic interventions has been tried –drugs or anesthesia – and each has such potentially grim consequences

Unfortunately, drugs lead to MORE drugs. As an L&D nurse in the early 1960s, narcotics given during labor and general anesthesia was the universal way to manage labor pain. Unfortunately, a seasoned OB doctor that I worked with informed me that death from anesthesia-related complications was the 3^rd leading cause of maternal mortality in 1960. So we are inevitably lead back to square one – non-drug methods of coping with labor, one contraction at a time. Unmedicated labors are safer and far less likely to trigger the familiar cascade of unintended consequences that can lead to operative delivery.

The problem for modern obstetricians is that his hands are tied. The modern hospital environment presents the modern laboring woman with few options for physiological management and a built-in series of small “bumps” that constantly risk derailing the natural process. Once the mother is sitting on the side of the bed in the labor room, the only reliable strategy for pain management in the institutional environment is either repeated injections of narcotics or epidural anesthesia. Both have a really negative effect on the progress of labor, especially if given too early.

Labor is a ‘subtle’ system, sharing the same endogenous hormones and the same delicate mind-body connection that is more familiar to us in regard to human sexuality. During labor, exogenous sources of hormones or narcotics have the same effect that a 1/16^th of an inch bump in the surface of a pool table has on the path of a cue ball. The ball, which was directly lined up to fall in the corner pocket, hits that little bump and goes just a little off track. However for every inch it travels, that error in direction is magnified until the original 1/16^th of an inch bump has changed the trajectory so much that the ball hits the bumper 10 inches off target.

Teaching moms before labor

So what do midwives do to deal with the difficult reality of labor pains? One part of the answer is that we talk about it and teach coping strategies ahead of time. This may include some form of “breathing technique” but of equal or greater importance is teaching a way to think about the experience of pain, to help demystify pain, to recognize the difference between the pain of injury and the “normal” pain of labor, which is pain with a purpose, pain that accomplishes something of value. This simple stance invites women to make peace with the idea of labor pain. Fearing and fighting pain always and only makes it more difficult.

It is possible to develop common sense strategies to deal with transient pain. Acceptance is one of them. I once watch a little gaggle of teenage boys deal with transient pain in a remarkably effective way. They were kicking a ball around on the street in front of my house when one of the boys got a minor but painful injury. In unison the rest of the kids chanted a line that must have been the advice of their football coach about how to handle pain. It was: Don’t sit down, don’t stop, don’t give up — just walk it out, repeated over and over again, until the kid was OK and able to play ball again.

Another bedrock of midwifery management is to discuss the possible value of tolerating the noxious sensations of labor. When drugs and anesthesia are presented to women as the preferred response to labor pain, it communicates the idea that the hard work and often painful nature of childbearing has no redeeming value, serves no purpose for mothers or society. This can be viewed as an unconscious form of sexism, which perceives childbearing women as biologically or psychologically unable to cope. In an era of reality TV shows, with women contestants running marathons, climbing mountains, swimming with sharks and eating big, slimy disgusting bugs, it wonders me that women can be convinced to have a scheduled C-section, because childbirth is just ‘too hard’.

In so many other areas of an adult woman’s life — sports, schooling, professional, political or artistic achievements — we honor her hard work, respect the determination it takes, we provide effective and sympathetic support for the painful aspects of her efforts and celebrate it as a victory when she succeeds. But for childbirth, we don’t value or respect the hard work of labor or provide the circumstances for its success. In fact, we do just the opposite — we tell women they are crazy to even try a natural birth and sabotage the mother’s best efforts by asking every 20 minutes if she’s “ready for her epidural yet”.

I once watched a televised Olympic marathon, in which one of the women runners was weaving back and forth and staggering just 20 feet from the finish line. However, she was still on her own two feet and still making some forward progress. The voice of the announcer explained to the viewing audience that were someone to go out to “help” her, it would disqualify her from the event and the entire 25 and 9/10^th miles she had already run would be negated. Pity, which can be a laudable characteristic, would none the less have stolen an incredibly important personal victory from her.

I think of this analogy when medical personal suggest epidural anesthesia to a laboring woman who is already 8 or 9 centimeters or even completely dilated. The mother is afraid that she won’t be able to handle the birth. Yes, she has pain but the deal breaker is the fear. Instead of offering reassurance, encouragement and confidence that she can do it, pointing out that she has already accomplished the lion’s share of the work – 23 ½ miles of the 26 mile marathon — they adopt a ‘value-neutral’ attitude and just call for the anesthesiologist.

I know from experience with many women under these circumstances that they often believe they simply didn’t have what it took. I also see a similar phenomenon when doctors want to “help the mother out” by using vacuum extraction to deliver the baby and shorten 2^nd stage by 10 or 15 minutes. The mother will be inappropriately grateful to the doctor, believing that without this help she wouldn’t have been able to do it or her body just wasn’t ‘built’ to give birth. This attitude is sometimes passed on to her daughters as the idea that women in their family have genetically defective pelvises.

An effective pieces of advice to the mother and her ‘coach’ is to “do” labor a half hour at a time. This forestalls the feeling of being overwhelmed. Most people can put up with most things for 30 minutes. So we reassess at the end of every half hour to see if the techniques and coping skills were working for her, and if not, to try something new.

A good midwifery strategy for managing the experience of pain is to let laboring women now that if they can get to 5 or 6 or so centimeter of dilation, they will have experienced the “it” that labor is. Labor at 7, 8 or 9 centimeters is more of the same, it isn’t a geometrical progression in which the strong sensation of 8 or 9 centimeter are twice as painful as they were at 4 or 5 centimeters. If they can get to 5, chances are good that they can get to 10.

Another aspect of this type of patient education and preparation is to know that “hitting the wall” is a very normal experience, one that often indicates that she is just about to break thru to the pushing phase (first time mom) or about to give birth (second or subsequent baby). This provides some psychological comfort in that experience, replacing fear and overwhelm with the encouraging knowledge that the labor is coming to an end and baby is about to be born.

Managing Labor Pain, one contraction at a time

First, mother laboring at home get up and move about freely in a place that is familiar to her and affords her psychological privacy. Both movement and psychological privacy are important. If you’ve ever hit your thumb with a hammer you’ll be familiar with the need shake your hand while moving rapidly around the room and yelling “OWWW!”. Contemplate for a moment what it would be like if you were forced to hold REAL STILL and NOT MOVE! Horrible thought. So freely moving about is a good start.

End of draft version — will eventually be posted by topic instead of one long mixed-topic document

Dr Fantozzi, Chair, Midwifery Committee Medical Board of California / DOL

1426 Howe Ave Suite 54
Sacramento, Ca 94303
                                           916 / 263-2365

California College of Midwives
3889 Middlefield Road
Palo Alto, Ca 94303

June 24, 2004

RE: Midwifery Committee Meeting May 6, 2004

Synopsis of topics in this correspondence:

(1)   Kill-Bill ~ Notification to the MBC of a request by the California College of Midwives and California Citizens for Health Freedom to Senator Liz Figueroa to either repeal the supervision / standard of care provision of SB1950 or pass remedial legislation statutorily defining the appropriate standard of care for LMs to be an evidence-based midwifery standard as used by the California community of profession midwives and supported by the scientific literature

(2)   To inform you that a two-notebook set of scientific literature on physiological principles, midwifery practice and intrapartum management in domiciliary settings will be provided to you at the next Midwifery Committee meeting. A second set will also be presented to the MBC staff, along with the California College of Midwives’ ‘Blue book’ of Generally Accepted Practices (GAP) [Note: Dr Karlan already has a copy of the scientific literature 2-book set]

(3)   To express the belief by the California community of midwives that all members of the MBC directly involved in making decisions (voting, etc) in regard to the practice of licensed midwives have a due diligence obligation to be knowledge of the information presented in the scientific literature, including the fact that there is a broad consensus of scientific data supporting the social model of maternity care in domiciliary setting — a safe and cost-effective method that depends on the use physiological principles and a minimally interventionist style used by midwives and a few family practice physicians

(4)   To identify an effective political/legal responses by the College of Midwives and CCfHH to address and correct the underlying problem — the dysfunctional politics of organized medicine relative to topics of maternity care for healthy women with normal pregnancies.

Dear Dr. Fantozzi,

I want to personally acknowledge all your hard work as a MBC member. I know that chairing the Midwifery Committee is difficult and unpopular, a sure way not to make many friends. I and other licensed midwives thank you for becoming familiar with the messy aspects of this political controversy.

I know you are still wondering whether community-based midwifery represents a solid, science-based form of maternity care or a dangerous hippie cult. The burden of responsibility as a physician and a voting member of the Medical Board must create quite a crisis of conscience in regard to this matter. I

assure however, that the more you know, the more you will be convinced that physiological management is the evidenced-based model of maternity care. It is associated with the lowest rate of maternal and perinatal mortality, is protective of the mother’s pelvic floor, has the best psychological outcomes and the highest rate of breastfed babies. Use of physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative complications, delayed and downstream complications in future pregnancies.

By comparison, conventional obstetrics as applied to healthy women is the opposite of evidence-based, physiological management. Its associated with high levels of medical intervention, obstetrical complications, anesthetic use, instrumental deliveries, Cesarean surgery and post-operative complications including emergency hysterectomy, delayed complications such as stress incontinence and pelvic organ prolapse, downstream complications in future pregnancies such as placental abnormalities and stillbirths, long-term psychological problems such as postpartum depression, lower rates of breastfeeding and increased rates of asthma in babies born by cesarean section. Conventional obstetrics for healthy women is neither safe nor cost-effective.

A long over-due, and much needed reform of our national health care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. Physiological management should be the foremost standard for all healthy women with normal pregnancies, used by all practitioners (physicians and midwives) and for all birth settings (home, hospital, birth center). This “social model” of normal childbirth includes the appropriate use of obstetrical intervention for complications or at the mother’s request.

Due to the historical agenda of organized medicine to discredit physiologic principles and the conventions of tort law, midwives are currently the only professional maternity care providers that are trained, skilled, experienced and legally able to provide physiological management for healthy women with normal pregnancies.

An ethical response to this dilemma would trigger ACOG policy reform, which would prompt medical schools to teach the philosophy, principles and skills of physiological management to medical students, practicing physicians to learn and use the strategies of physiological management and insurance companies to reimburse obstetricians for this safe and cost-effective care.

As you well know, this is differently not happening. Instead, healthy childbearing families, hospital-based nurse midwifery programs and professional midwives of all backgrounds face extremely serious problems under our highly politicalized and deeply dysfunctional obstetrical system. The many controversies currently bedeviling the licensed midwifery program are only symptoms of this dysfunction system.

The underlying Issues

The MBC and its midwife licentiates are both being held hostage by this dysfunctional system. This political situation is beyond the scope of either midwives or the Medical Board to remedy or even to address directly. The actual problem is the historical agenda of organized medicine to gain control over the provision of all forms of healthcare and to fight against all non-physician practitioners.

Neither the Medical Board nor the California College of Midwives can require the cooperation of these groups or block their political influence. Medical associations are obviously exercising their constitutional rights – unfortunately, its much to the public’s detriment. For nearly a hundred years, this situation has been negatively influencing midwifery practice and its regulation by state governments, and still no end in sight.

The Medical Board’s response to threats of litigation by the CMA and ACOG appears to be a strategy of indefinitely postponing definitive action on controversial midwifery-related agenda items. The tone of the last Board meeting reminded me of the 1950s peace talks between North and South Korea – they spent the first two years arguing about the shape of the table and never actually were able to bring an end to the war. Permanent stalemate is the name of that game.

Such a stalemate applied to this situation brings up the specter of one or two (or more!) years of legal wrangling, with many contentious meetings, regulatory hearings scheduled, prepared for, postponed, testimony solicited, rule-making files produced, letters back and forth to the Office of Administrative Law, etc ad nauseum. This is a needless expenditure of valuable time, talent and money for the Board and for the midwives — all to no avail.

A better Way ~

It seems that the midwives have only two viable options — either reiterate the style of the CMA by also threatening litigation or taking action to address and remedy the real or underlying problem. We like and respect the members and staff of the Medical Board and find the idea of suing one’s regulatory board to be both repugnant and counter-productive. Happily we have chosen the latter option — tackling the real problem. This permits our group to use those same resources of time and talent to advance the interests of the public, the success and safety of the licensed midwife/client relationship, to resonate with the public safety mission of the MBC and to facilitate the Board’s ability to do their regulatory job with grace and efficiency.

(A) To achieve these goals we have asked Senator Figuero’s office staff for a “Kill-Bill”, that is, to approach the Senator with our request to either kill or remedy the provision of SB 1950 that is currently causing such a major problem for both midwives and the Board. It seems prudent for the Medical Board to put any comparison studies relative to hospital-based obstetrical standards and midwifery management on hold until the Senator responds to our request, one way or another.

(B) We have created a new and broadly-based consumer organization – the Consortium for the Evidence-based practice of Obstetrics or “CEO”. The web site is www.ScienceBasedBirth.com. The purpose of CEO is to bring the attention of the public and the legislature to the profoundly dysfunctional nature of our current obstetrical system. The routine application of interventionist obstetrics on virtually all healthy women introduces artificial and unnecessary harm. At present, the obstetrical profession systematically fails in its most important job — to preserve and protect already healthy childbearing women..

Our first activity is a letter writing campaign – our goal is a 1,000 letters in a 100 days to California First Lady Maria Shriver. The direct purpose of this activity is:

1. To create a cohesive, broad-based and effective constituencymade up of consumers, taxpayers, childbirth and public health professionals committed to reforming our national maternity care policy
2. To bring about legislative hearings on the issues identified in the CEO White Paper,including the off-label use of Cytotec for labor induction, the ever-climbing cesarean section and maternal mortality rate, the danger in promoting the maternal choice cesarean as the so-called ‘ideal’ form of childbirth and the physically damaging effects on the integrity of the pelvic floor and pelvic organs associated with the current, medically-interventive management of vaginal birth
3. To facilitate passage of legislation mandating that physicians obtain true informed consent before substituting medical and surgical interventions in place of the safer, evidence-based principles of physiological management and that they provide full information about the risks of medical or surgical intervention and obtain consent before implementation.

Conclusion

Speaking on behalf of mothers and midwives both, we believe that the only way to resolve the intractable licensing and practice issues noted earlier is to fundamentally change the public discourse between women and ACOG. This is to be accomplished by first winning in the court of public opinion and then, if necessary, in a court of law and finally in the legislature. The law must changed for both midwives and obstetricians.

The ‘physician supervision clause’ in the certified nurse-midwife and licensed midwifery acts must be repealed. It creates unnatural and unnecessary vicarious liability for physicians, which totally blocks their ability to appropriately consult with midwives or provide necessary hospital care for midwifery clients.

CMA lobbyists promised the Legislature that a licensing law requiring physician supervision would promote public safety by guaranteeing appropriate access to medical services by pregnant women. Instead of the promised stepping-stone, this provision of the LMPA turned out to be a stumbling block, which creates unnecessary and unnatural hazards.

The only solution is for midwifery to be an autonomous profession. The current unworkable relationship between physicians and midwives must be replaced with a voluntary one defined as ‘collaborative’, in which midwives consult with physicians as needed and are respected by medical and obstetrical providers as colleagues.

Until the LMPA is appropriately amended, the Medical Board will be unable to do its regulatory job with either grace or efficiency in regard to licensed midwifery and LMs will continue to be denied the simple human dignity of being able to be in compliance with our licensing law.

I look forward to seeing you at the next Midwifery Committee meeting on July 29^th.

Faith Gibson, LM, CPM,

Executive Director, American College of Community Midwives
Coordinator, California College of Midwives (ACCM state chapter)

Cc:       Senator Figueroa’s office
MBC DOL Linda Morris
Frank Cuny, Director, California Citizens for Health Freedom
Megan Roy, CAM // MBC Liaison

California College Of Midwives

{Work-n-Progress as original file incompatible with WordPress — changes all apostrophes to questions marks “?”}

February 10, 2003

TO: Dr Fantozzi, MD; Midwifery Task Force, Member – MBC

RE: Our organization’s official opposition to the MBC’s currently proposed midwifery Standard of Care (per SB 1950, Figueroa, 2002)

Other members of the California College of Midwives present at the Saturday, Feb 1^st General Meeting reported that the Board’s formal position on the implementation of SB 1950 was quite different than the statement read during the Friday DOL meeting.

As described, the Board’s conclusion appeared to reflect the position of the two American College of Obstetricians & Gynecologists representatives who spoke on behalf of ACOG’s District IX. As we are all aware, ACOG’s position is that the hospital-transfer issue makes home-based birth care unacceptably dangerous.

In spite of the plain language in the legislative intent and body of the LMPA, ACOG spokesmen continue to act as if the MBC has a legal duty to restrict the care of professionally-licensed midwives and should use its authority to the promulgation of regulations restricting the practice of licensed midwives to acute-care hospitals and state licensed birth centers. They apparently read something in the black-letter law of SB 1950 that isn’t apparent to midwives and mothers.

Alone with the rejecting planed home birth services as provided by LMs, obstetricians also fight tooth and nail against granting hospital privileges to LMs. With rate exception, they refuse to serve as medial directors for free-standing birth centers, which are necessary for birth centers in California to operate.

However, the elimination of legal home birth practitioners would do much to re-create lay midwifery, revive practice under the religious exemptions clause and promote unattended labor and birth at home.

I must mention that as an L&D nurse, ACOG obstetricians were perfectly happy to leave their actively laboring patient in my care in the middle of the night in small community hospital with no in-house physician.

While these midwife-unfriendly doctors slept peacefully in their beds at home (minimum travel time of 10 to 20 minutes) I attempted to give my professional attention to women in four labor rooms and one OR, with the added responsibility of post-anesthesia recovery of newly delivered women and helping new mothers breastfeed for the first time.

Practically speaking, this meant that I was only able to be present with each laboring women for 3 to 7 minutes every 30 minutes to auscultate FHTs (or read the EFM strip), take vital signs and monitor progress via vaginal exams. I spent considerably more time with the chart than the patient.

I was usually out of the room for 45 minutes of every hour, either leaving the mother alone or in the care of lay persons such as a family member. (A recently published study on L&D nursing discovered that labor room nurses are out of the labor room 79% of the time.) By the time I (and other busy L&D nurses) detected fetal distress, a prolapsed cord or a PP hemorrhage and notified the obstetrician & anesthesiologist who had to dress and drive to the hospital, it was often at least as long (if not longer) than the typical hospital transfer of a midwifery client. And being out of the labor room for three-quarters of an hour, I had no idea how long the complication went undetected before this emergency response was put into play.

I notice that ACOG is perfectly comfortable with this on going situation.

In home-based midwifery care, the ratio of practitioner-to-patient is always one to one. The continuity of care in community-based midwifery is always an advantage. A skilled midwife is an educated observer with emergency response capacity. An unattended birth is always one in which there is no educated observer present and no has the capacity to effectively intervene in case of an emergency. I can’t imagine why ACOG would want to promote unattended home births by making professional midwives unavailable to childbearing women.

When emergent conditions arise, the midwife calls ahead (cell phones are a wonderful adjunct to this early warning system) and notifies the hospital so they can contact the doctor at home. By the time he dresses and drives to the hospital (the same 10 to 20 minutes), the patient, midwife and doctor often converge in the hallway on route to the labor room.

It is an interesting phenomenon that the same doctors who are outraged at the thought of mothers laboring at home are perfectly happy to be at home themselves while their patients labor at the hospital 20 minutes away in the care of over-worked and often inexperienced nurses.

Historic failures of the obstetrical profession to adequately and safely serve healthy women with normal pregnancies

The current controversies in community-based midwifery actually represent the failures of the obstetrical profession to adequately and safely serve healthy women with normal pregnancies.

This is not personal opinion but well-supported fact. This institutionalized inadequacy sets up childbearing women who have a normal pregnancy but also have an identified risks factors, such as breech, twin or post-Cesarean status, to reject the interventionist practices of obstetrical medicine. In an ideal world, these moderate-risk labors would be managed “physiologically” in a hospital by midwives under circumstances best described by the Dutch phrase “a relocated home birth”. This would truly be the best of both worlds — the successful use of time-test methods historically known as the “midwifery model of care” in conjunction with immediate access to all the technology of modern medicine and the technical expertise of obstetricians.

Organized medicine brought this crisis about in two very specific ways – a hundred year history of obstructing the independent practice of midwifery and attempting to criminalize its practice and their irrational enthusiasm for an interventionist model of care for healthy women despite its deleterious consequences for mothers and babies.

Organized medicine’s historical rejection of physiological management was formalized in the United States in 1910. It was accompanied by an aggressive campaign to eliminate the so-called “midwife problem” by eliminating midwives. The fallacious claim that “midwives kill babies” and doctors save them was the profession’s propaganda slogan. This clearly conflicted with all scientific evidence as reported by a few honest physicians of the time.

The uninformed testimony of the two ACOG reps at the Boards’ Task Force meeting just 3 days ago tells us that little has changed in the intervening 90-plus years. This is the reason there have been no professional midwifery training programs or state licensure of midwives for most of the last hundred years. It is also why, in contemporary times, we do not have a cost-effective, seamless and mainstream system of maternity care as enjoyed by Dutch mother in The Netherlands.

The second act of this drama as orchestrated by organized medicine is the shameless promotion of an ever increasing medicalization of normal labor which had dominated obstetrical practice for the last century.

This irrationality equals an unhistoric “flat earth obstetrics” that is keeps pushing and pushing the envelope until  arriving at the most dangerous of all “labor-saving devices” — the medically-unnecessary, “maternal-choice” Cesarean surgery.

This predilection creates an ever-widening stream of maternal complications and preventable maternal mortality. It also fueled a backlash in which national organizations such an the International Cesarean Awareness Network (ICAN) have arisen and include many previous Cesarean mothers who are flatly declining medical advise for an elective repeat Cesarean.

These mothers have already experienced one or more highly medicalized hospital labors in which they were immobilized in bed with IV lines and a tangle of cords that lead to the continuous electronic fetal monitoring system. It did not end well for them and when I suggest a hospital VBAC, they say: “I refuse to return to the scene of the crime“, which is how they viewed their experience.

 

Women often identify the massive quantity of routine interventions and protocols that have become the hospital norm as the iatrogenic cause of their previous Cesarean and want no part of this repeat performance.

Over-treatment always has an equal or greater potential for resulting in serious complications and even maternal mortality as any type of “under treatment”. It is not automatically superior to suffer from over treatment and is especially tragic when the woman and her pregnancy was healthy to begin with and the problems were iatrogenic in origin.

ACOG has used it’s consider influence to make the American public pathologically afraid of normal childbirth, all out of proportion to the actual dangers to healthy women with appropriate access to our modern system of health care. This sets women up to be hysterical frightened by labor and seek out (or be advised by their doctor to seek out) inappropriately early hospitalization, long before the onset of progressive labor.

This iatrogenic problem is supposedly “solved” by the routine use of oxytocin to induce or augment latent labor. Artificially accelerated labor is exquisitely painful and leads almost inevitably to the need for an epidural. Anesthesia further slows labor, requiring IV Pitocin, which can and often does precipitates fetal stress. This means the mother must be put on oxygen, giving everyone the impression of great danger.

If the labor does not progress rapidly at that point, it sets up a situation that will frequently requires use of forceps or vacuum extraction or Cesarean delivery for fetal distress or “failure to progress”.  However the real failure was obstetricians couldn’t or wouldn’t keep their Pitocin and other obstetrical toys for patients who really needed and benefited from them.

The bottom line is the failure to the obstetrical profession to teach, learn and utilize physiological management as the foremost standard for healthy women with normal pregnancies. This results in inappropriate medicalization (early hospitalization with IVs, Pitocin, artificial rupture of membranes, continuous electronic monitoring, epidural anesthesia) mechanization (forceps or vacuum extraction) and/or surgery such as episiotomy and Cesarean section.

This jeopardizes the well being of mothers and babies, increases maternal complications both during and after the birth such as infection, blood clots, pulmonary embolisms, hemorrhage, emergency hysterectomy and all the immediate, delayed and downstream complication in post-cesarean pregnancies, many of which are fatal. It represent a lack of due diligence for any professional birth attendant to be ignorant of these science-based realities, which are freely acknowledged by many individuals within the obstetrical and scientific community and available to anyone with the time or interest to google them on the Internet.

From the stand point of the Medical Board and its official activities as the regulatory body of both obstetricians and licensed midwives, it would be a lack of due diligence were its representatives to remain uninformed of these crucial facts and their influence on both the practice of LMs and the demands of the healthy childbearing public, which is unable to obtain safe and appropriate care from the obstetrical community in far too many instances.

It is my understanding that the legal obligation of the MBC is to license appropriately trained and qualified medical practitioners and to discipline these licentiates if they violate their professional standard of care.

For better or for worse, the Board itself does not at this time set standards for any profession under its authority. That determination occurs as a result of the expert review process by a bona fide member of the discipline in question.

Despite ACOG?s contrarian perspective, SB 1950 does not direct the medical board to define “safety” or propagate a midwifery standard of care on its own and separate from the community of licensed midwives. The legislative language uses the word “adopt”, not define or develop. While the original LMPA does not identify home birth as the sole or even central setting for intrapartum care, or otherwise address the “safety” of planned out-of-hospital (OOH) midwifery care. However, the 2000 Figueroa amendment (SB 1479) does defines the “midwifery model of care” and identifies that “home” as a safe choice for mothers based on access to professional, community-based midwifery care as intrinsic to the safety of the parents’ lawful choice of an OOH setting.

Were I in charge of how maternity care was offered by professional attendants in California, I would requires medical schools to teach midwifery as a historic and contemporary discipline and for ACOG to be sure that currently practicing obstetricians receive continuing education in the physiological management of labor and birth. I would insist that public pronouncements by ACOG and individual obstetricians that falsely promoted elective cesareans as the superior and safer choice for parents to be a false claim that equated to unprofessional conduct. At that point, I would expect the MBC to investigate and file disciplinary charges against these physicians.

I know this letter is unconsciously long and it content controversial, and for I apologize. However, the bottom line is actually quite simple. The MBC did not write the standard of care for the practice of obstetrics, because the rightful organization to propagate such a document is the members of the obstetrical profession themselves. The right organization to propagate a standard of care for the practice of community-based midwifery are professional licensed midwives themselves.   I doesn’t get any simpler than that.

I thank you for you time. If you have any questions or comments, I may be reached by email at “faithgibson@mac.com”

Warm regards,

Faith Gibson, Ca LM 041