California College of Midwives

by Tonya Brooks

I. Midwives’ highest priority is to provide a higher level of safety to pregnant women than is currently available. This is done through a marriage of 

    a. “up to date” science.

    b. one to one care,

    c. competency

    d. thorough knowledge of alternative health care and treatment modalities including but not limited to nutrition, chiropractic, acupuncture, homeopathy, and herbs.

    e. thorough knowledge of the medical model of care.

II. Midwives might do more, less or something different than traditional physicians, but this would be done with a thorough knowledge of the medical standard of care in the community, and the alternative care would be done always in consideration of long term outcomes.

III. The “midwifery” and “medical models”of care are actually based on the same science, proven truths, operating principals, and are in fact a ladder of technology that is applied at the level most likely to produce the best patient results and the best long term outcomes for mother and infants.

IV. “The less intervention with nature the better” will improve outcomes in low risk mothers, but is the opposite is true with high risk patients or those with certain risk factors.

V. There is a gradient of risk factors defined to the best of our scientific knowledge where pregnant mothers fall actually into five categories:

    Low Risk,

    Moderate Risk,

    Intermediate Risk,

    High Risk, and 

    Identified multiple risk.

VI. Women with risk factors need access to alternative health care as well as the sophisticated diagnostics of the medical doctors. This document acknowledges that current technology for diagnosing enhances our clinical knowledge but does little to “cure” the problem. Pregnant women need the wisdom of both medical and midwifery approaches to give the best physical, emotional, and spiritual outcome. Therefore, integrated practices have the best hope of forwarding midwifery science into the future.

VII. There is no law or rule made by man, government, or God that disallows a woman to choose to procreate or not, her place of giving birth, or her care giver. These are fundamental human rights.

VIII. Likewise, it is the choice of every woman to seek or not seek care even if we think she should. But knowledge of risk and probable outcome is her right and responsibility. Should a pregnant woman seek midwifery or medical care, the availability of options, providers of care, and places of birth is the right of every woman and the responsibility of midwives and physicians. 

IX. The government has the responsibility to insure those choices exist because no one group has cornered the market on knowledge. The government cannot regulate the place of birth but only the actions of licensees.

X. No hospital, medical group, or insurance provider has the right to dictate choice of providers or place of birth.  However, insurance providers have their own rules regarding who they will pay.  The factual basis of these rules and their effects on pregnant women’s choices need to be scrutinized.

XI. With these rights of pregnant women have come the right and responsibility to education and for informed consent.

XII. The childbearing public has the right to make decisions with which midwives or physicians disagree, but  midwives and physicians can refuse to support or condone or back up those actions. 

XIII. The rights to informed consent must include:

    1) Knowledge and explanation of any procedure and why it is being done, in language that the woman understands.

    2) the right to know and be informed of the benefits and risks of alternative procedures including doing NOTHING.

    3) Without all three the pregnant woman patient cannot understand why the provider would suggest one treatment over another.

XIV. Midwifery patients have the:

    1) right to physician back up. If the midwife is unable to obtain medical back up it is The midwife’s responsibility to oversee transport to an ER with an on call team and stay with the patient for continuity of care.

    2) It is also the mother’s right to produce her own back up physician.

XV. In order to insure the safety of her patient, all midwives need to work diligently on helping physicians with patient care, building respect for the doctor and basically integrating her knowledge and skills into established health care of her community. This makes the midwife a valuable addition to the team. The midwife has the right and responsibility (as does the physician) to give a second opinion.

XVI. No physician is responsible for care given by midwives or decisions the midwives make prior to transfer of care unless the physician ordered the midwife to do a procedure.

XVII. Physicians who receive laboring patients have the right to foreknowledge of the patient (ideally early) transfers, complete records, compete truth on what has transpired.

Mothers’ birth experience, outcomes and comfort are greatly enhanced by the midwives continued presence as part of the team.

XVIII. Physicians have the right to refuse to support procedures with which they disagree, in or out of the hospital. Midwives have the same rights.

XIX. Physicians and midwives have the right and responsibility to make individual care plans and protocols for patients with risk factors who request special considerations for alternative birth including

    1) request VBAC

    2) other risk factors in which the patients seek alternative care

    3) unusual or rare circumstances.

XX. Individual patient protocols demonstrate a well thought out plan of care including high level one to one care by the midwife who would then report to the physician in the previously described condition.

Women’s’ Health Care

Reproduction and Gynecology

I. Midwives have the right and responsibility to do  well woman screening and gynecology, family planning, nutrition, breast screening and other issues related to reproductive and public health.

II. Midwives have a responsibility to follow up on basic tests and to make sure their patient is referred to a competent gynecologist or other physician specialist should there be a result requiring advanced care.

III. The midwife has the responsibility to make sure that patient was seen and further work ups and procedure completed to insure her patient’s safety.

IV. Midwives may be utilized to improve the public safety as  an important first step in public health screening or complicated work ups. Midwives have a broad outreach to the public a place in prevention programs. The midwives care is ideal for triaging the public into the correct physician specialist.

V. Public outreach screenings vary depending on how rural, isolated, or urban the midwives practices may be.

Copywrite 2005 by Tonya Brooks

The following video is Numer Ono in my oral history project. I think the verbal telling these stories, along with links to historical resources, pertinent documents and other materials, is a “Best Practices” when it come to both the history and the politics of midwifery.

[youtube]http://www.youtube.com/watch?v=BmuK5IP41fw[/youtube]

That said, the following video is kind of boring to just sit and watch. As oral history, it more for listening than watching.

Personally,  I played the original footage while cleaning off the top of my messy desk. An alternative would be to take your laptop to the kitchen and listen while you fix dinner.

Future videos will include interviews, graphics and one hopes, a more interesting format.

In the meantime, I hope you enjoy the first of many opportunities to memorialize the historic or “legacy’ pratice of midwifery, and the story of our struggle from an outlaw group of persecuted and prosecuted ‘lay’ midwives  to licensed midwives who have so far won many battles.

However, we haven’t yet won the right to vote — that is, to be fully functional professionals in control of our own profession and in charge of our own individual pratice with out have to grovel and beg to get access necessary medical care for our clients and their babies.

Cal govt. code section 11349.1 that requires regulations to conform to the following 6 criteria:

necessity, authority, clarity, consistency, reference, and non-duplication

http://transform.childbirthconnection.org/reports/liability/

This is a re-posting of the last half of yesterday’s report on the Council meeting. 

I am troubled by ACOG’s proposals for a couple of reasons

As many of you know, I organized a professional liability insurance consortium that covered 55 LMs and CNMs providing OOH birth in three states (Ca, NM, Fla) for three years (1998, 1999, and 2000). Ann Geisler from Dean Insurance was our broker. Over a three year period, the 55 of us paid out $250,000 in premiums.  Let me say that again to be certain we all properly appreciate what a GREAT big number came from such a tiny number of midwives!

A small group of supposedly poor midwives paid on average from $1200 to $2500 annually. That was $100-200 a month as a proportional premium based on numbers of birth attended the previous year (generally from 10 to 25 births a year). That scraggily little handful of midwives paid a total of more than a 1/4 million dollars in premiums.

In spire of this considerable expense (and three years of massive unpaid work on my part!) California LMs who carried professional liability insurance discovered that the general anti-midwife/anti-PHB stance of ACOG and our local obstetricians remained unchanged. Several doctors and ACOG reps said: “The only thing better than one deep pocket is two deep pockets“.

With that, I and all the other LMs discovered that being insured made no difference whatsoever. As Dr. Klein from the Canadian Maternity Care Discussion Group has remarked in relation to the obstreperous nature of obstetrics (defined by Webster as “noisy and defiant”): “when you don’t want to do something, then one reason is just as a good as another“.

What if we had either self-insured OR spent our Big Bucks to buy our own politician instead?

I couldn’t help but wonder how this situation would have turned out if we’d spent that same $1/4 million dollars to get good legal advise, hire a hot lobbying firm in Sacramento, identify legislators willing to support mfry-friendly legislation and then contributed ‘generously’ to their re-election campaigns. Organized medicine should not be the only one who can play the game of the “best damn government money can buy”.

Instead we dumped 1/4 million bucks into the coffers of Evanston Insurance and Royal Surplus Lines. By the way, none of the quarter million went to benefit a harmed childbearing family, as no claims were ever paid out.

And according to very reliable sources,  there has never been a successful vicarious liability lawsuit in California relative to OOH midwifery.

Changes in ACOG policy need to accompany changes proposed by ACOG to the LMPA

If District IX ACOG is serious about having their Fellows formally cooperating with California LMs who provide PHB care as matter of law (new amendments to the LMPA), then their national anti-PHB policies will have to be amended. Since 1975, physician participation in PHB or having a working arrangement with a PHB midwife  has constituted a substandard practice of obstetrics for an ACOG fellow. Should there be a lawsuit, no med-mal carrier could successfully defend an obstetrician, as no ACOG-certified ‘expert’ witness could or would testify on his behalf.

In addition, plaintiff attorneys could admit into testimony the many policy statements warning issued in 1975, 1979, 1999, 2004, 2006 and 20008 (unsure of last date) counseling against the participation of obstetricians. Over the years, these have only grown more strident. Plaintiff’s attorney could line obstetricians up around the block to recount the many papers published in peer-reviewed obstetrical journal filled with dire warnings. They routinely defined PHB as sub-standard care any physician trained in the surgical specialty of obstetrics. The most recent was presented in November 1012 at an international conference in Paris. It states that the risks of planned home birth can only be eliminated by planning a hospital birth.

As obstetricians, the standard for any care they supervise must be consistent with the standard for the surgical specialty of obstetrics. From the other end of the same conundrum, they  can’t reasonably be expected to supervise a profession that they are not trained in themselves and have no idea what is and isn’t an appropriate practice of midwifery. As of this moment, ACOG remains on the horns of a dilemma, a prisoner of its own project to control the economic competition of midwifery by mandating its supervision by the obstetrical profession.

Back to basics ~ Any LMPA amendment must first and foremost improve the midwife-physician relationship 

My second trepidation with ACOG’s legislative plan is that we are no longer working on a plan to improve the working relationship between midwives and physicians.

Instead we have taken a major left turn, and now we are:

• Trying to make supervision work by getting med-mal carriers to cover OBs who supervise OOH midwives
• Getting legislation to create a new State-sponsored JUA
• Figure out how to take $$$ from California’s share of the ACA and redirect it to medical malpractice carriers

Perhaps I am naive, but i’d like to see California’s share of ACA money go to expand healthcare coverage for the uninsured, provide better quality services, and create or expand educational and support programs to reduce obesity, type II diabetes and other expensive chronic diseases.

So far, my take on AB 1308 is a diversionary tactic that is to keep us all busy elsewhere, instead of working to actually change the relationship between midwives and physician for the better. Insuring midwives on the public dole of the ACA is not necessary and its not good public policy.

What we need instead is parity of obligations — any obligation that ACOG wants to impose on midwives must be mirrored in an equal obligation by obstetricians to fully cooperate with achieving the legislatively identified goal. If ever the old-fashioned expression “What’s gravy for the goose is gravy for the gander” applied in modern times, it is in regard to the idea of equal obligations between our two professions.

The track record of cooperation by ACOG  over the last 39 years is abysmal — in fact, its an unbroken record of non-cooperation. Twenty years ago this June the CMA promised Senator Lucy Killea that if she would let them insert the same physician supervision clause in the LMPA already proven not to work in the Nurse Midwifery Practice Act, CMA would “see to it that physicians provided supervision to licensed midwives”. We all know how that turned out.

Considering such a poor record, any midwife-physician relationship defined in legislation or other policies to be used to propagate such regulations,  much have provisions in the authorizing legislation for the following:

• Collaboration and consultation by California licensed obstetricians with California licensed midwives must be acknowledged as a normal obligation of the license to practice of medicine in California
• Professional liability insures who are domiciled in California (therefore regulated by the California Insurance Commission) must cover any incidental liability (either vicarious or direct) associated with the normal professional relationship between MDs and LMs as a normal part of the premiums already paid for standard obstetrical liability insurance
• Compliance by physicians with new legislative-defined relationship must be be measurable and must identify a method to formally track outcomes (i.e., reports of non-compliance)
• A ‘sunset clause’ must be included in the legislation that requires to be re-visited by the legislature in 2 years to determine the success or failure of these new rules

Tomorrow I will explain why I resigned yesterday as a member of the Mfry Council, and what that means for me and others.

• Sunset Review reports provided by Medical Board staff, ACOG lobbyist, and the CMA
• TIme line for Sunset Review bill ~ language not available until April, must be passed by June 6th
• ACOG introduces AB 1308 to amend LMPA and ideas for malpractice coverage of midwives under the Affordable Care Act 2009 (Obama care)
• Faith Gibson resigns from the Midwifery Advisory Council
• Next Council meeting scheduled for August 8th, 2913

The Midwifery Advisory Council met yesterday at the State office of the Medical Board in Sacramento. There was no simultaneous webcast, but a member of staff did video tape the meeting. Board staff said it will be posted on the Medical Board’s website in a day or two (today or Monday.

I really urge midwives to watch the video and hear what was said for themselves.

The meeting was well-attended by midwives and mfry supporters (19), by MedBd staff (9) by representative of organized medicine (3) and of course, 5 members of the Council (total 37 persons present). It was also unusually short, as there was no work session on a particular topic.

Instead the bulk of the one and a half hour meeting consisted of reports by about the Sunset Review Committee hearing on Monday, March 11th and proposed introduction of legislation. The staff reported that there would be no further Senate Business and Professions Committee meetings. I found this to be a chilling bit of news. It means they actually scheduled the ONLY hearing in such a way that midwifery was never on the public agenda. It seems to have been a fluke that our issues got included in the legislative action plan.

As for the B&P Committee’s recommendations for midwfiery-related legislation, we currently know nothing except that it will come out in mid-to-late April. As a one-year bill, rules require that it be passed by June 6th. This means our ability to influence its contents will be very short (late April and month of May).

Legislative Proposals by CMA-ACOG

ACOG lobbyist Shannon Smith-Crowley gave a report on the actions of her group and the CMA to carry a bill to amend the LMPA by redefining the relationship between midwives and physicians and expanding the Licensed Midwives Annual Report (LMAR).

ACOG’s wants to make their midwifery bill a collaborative product between our two professional groups.  But so far CAM president Constance Rock has only had one conversation with Shannon, which consisted of Shannon providing information on what ACOG’s plans were and that no legislative language was available yet. On another occasion, Mfry Council chair Carrie Sparrevohn had the same experience, which is to say that mutual dialogue between our two groups may (we all hope) happen in the future but has not been realized so far.

As we all milled around after the meeting Shannon generally commented to all of us that it was possible midwives would not like all the provisions of ACOG’s bill, but hoped we would accept their bill as a 90% fix and support the final product as a joint venture.

Unfortunately ACOG still did not have any specific language to share, so the various individual conversations between Constance and Shannon and Carrie and Shannon have yet to offer any opportunity to actually negotiate  the content of ACOG’s proposed legislation. Shannon said AB 1308 could be accessed at www.leginfo.ca.gov either today (Friday -3-15-13) or Monday. Using the URL, I found AB 1308 by Assembly woman Susan Bonilla today, but at 1 pm there was still absolutely NO usual information.

LMAR & Possibility of replacing OSHPD on-line form with MANA stats projects

As for ACOG’s position on the LMAR , they are suggesting we use the “Vermont model”, which requires licensed midwives to file both a state form (for us the current OSHPD form) as well submitting MANA stats. They think this is a better option, as there are questions and topics on the state form (such as the number of midwives that attend births under physician supervision) that are not currently part of the MANA collection of statistics. Personally, I would suggest asking MANA to add those questions to their form.

Physician Supervision Provision of the LMPA

As for the relationship between midwives and physicians, they believe the current inability of obstetricians to supervise and collaborate with midwives is essentially a professional liability problem. Shannon did not address the physician-end of the issue in detail, but did mention the Insurance Commissioner. On another occasion, Julia De Angelo-Felmeth spoke at a Medical Board meeting and stated that if the law requires midwives to be supervised by physicians, the State department of insurance could require the professional liability carriers to cover that arrangement as a normal aspect of the standard coverage.

Malpractice insurance problems for ACOG fellows as focus of AB 1308

Shannon pointed out that as things stand now, any OB who supervises or collaborates with a midwife providing OOH care, or voluntarily accepts a transfer of care of a midwifery client, is doing so at great peril to his/her own professional career. For the last 39 years (since passage of the 1974 nurse-midwifery licensing law) official policies of all three California med-mal carries have prohibited any voluntary working relationship between physicians and midwives or between the doctors and midwifery clients who are planning an OOH birth.

In 1994 and 1995, the Medical Board held a total of 7 six-hour meetings of their Midwifery Implementation Committee. The lobbyist representing the California Association of Professional Liability Insurers (CAPLI) attended every meeting.  Judge Cologne was an attorney, former judge, one-time employee of the US Justice Department’s Anti-trust unit and a very recent lobbyist for the CMA. We asked him to explain the factual basis of the exclusionary policy by all  CAPLI members, and provide information about actuarial data being used. Judge Cologne cheerfully admitted that none of the companies had any actuarial data.

He described the prohibitive policy as an executive decision made the Boards of Directors of each of the three carriers. They generally believed that childbirth was a very dangerous affair, and that it was “just common sense that home birth would be even riskier than hospital birth”. As a result, their companies could not possibly cover  their insured doctors unless they were paying a steep ‘surcharge’ in addition to their regular premiums.

When asked how expensive  that would be, Judge Cologne estimated as much as an additional $50,000 per physician (average OB was paying about $45,000 for their med-mal insurance). He also mentioned the fiduciary obligation of med-mal carriers to drop the insurance of these physicians during the annual renewal. He identified the involvement of these doctors with such obviously risky practice (i.e., consulting and collaborating with PHB midwives and accepting intrapartum transfers of care) as confirming the physican’s poor judgement, at least from the standpoint of the insurance company’s interests.

For the last 4 decades, insurance carriers have to refused to defend a physician who was sued or pay out any claims involving the client of a licensed midwife. Since 1975, ACOG’s official policies have not supported PHB, or any individuals or groups that support PHB. For some reason ACOG is now quite concerned about the professional well-being of ACOG fellows who are currently cooperating with midwives.  At this point ACOG reps have not publicly proposed any specific solution or provided any information  except for the mention that perhaps the Insurance Commissioner should be contacted and a very casual remark by Shannon that perhaps a relationship that did not include supervision would be acceptable.

Mandating Malpractice Insurance for LMs

However, Shannon did talk about the midwife-end of the issue in some depth. ACOG believes that a serious stumbling block to workable arrangements between midwives and obstetricians is because midwives don’t generally carry liability insurance. ACOG is suggesting that a joint underwriters group be created to cover the liability risks incurred by midwives.

A joint underwriters association (JUA) is formed when laws require a group to be insured, but the insurance companies don’t see the economics of doing business with this group as profitable — for example, selling car insurance to those with a really bad driving record. This lack of profitability is generally due to a very high claims rate, or because the pool is too small to generate enough premiums to cover claims made.

In this case the malpractice premiums paid by midwives would go into a joint account shared by all three California-based med-mal carriers, and the cost of any claims would be jointly shared by all these carriers. Members companies of the JUA also get to set the rules (or in our case, the protocols) for what insured members of the JUA are ‘allowed’ to do (issues such as post-dates, PROM and VBAC, etc.

ACOG is suggesting that it might be able to make the premiums paid by midwives to the State-sponsored JUA  more affordable if ‘someone’ can figure out a way to use funds from the Affordable Care Act subsidize the insurance coverage of midwives.

Continued tomorrow ~ “I am troubled by ACOG’s proposals for a couple of reasons”

Good news for CaLMs — we had a great (and unexpected!) outcome at yesterday’s hearing.

We’d been lead to believe that the Senate B&P Committee was not willing to take on any “controversial” issues, which altogether eliminated addressing the midwife-physician supervision problem. For the first 5 1/2 hours of the hearing there was not a single mention of midwifery or any of the issues. Naming midwifery as a top priority when the Chair of the B&P Committee made his closing statement was a complete surprise to all of us.

Just prior to that, Carrie Sparrevohn, LM (chair-MAC) and Constance Rock, LM (president-CAM) both spoke on behalf of midwifery, as did Shannon Smith-Crowley (lobbyist-ACOG). Each of them added an informative perspective that was very helpful.  I don’t know if these comments made  the critical difference but always assume that being visible and having our voice heard is better than not speaking up.

During Senator Rich Gordon’s closing statement, he listed 4 areas of action for the Committee’s review. We were #4 — addressing the relationship between midwives and physicians.  As soon as the webcast is available, I will post video footage of the public comments about midwifery and Sen. Gordon’s final words on the Ca LMs website.

Senator Rich Gordon’s reframing of the ‘physician supervision problem’ as a relationship issue is brilliant! That is a much more successful way to talk about this topic when compared to remarks about ‘getting rid of physician supervision’.

The words “removing physician supervision” shall never again cross my lips!

Instead I’ll talk to Legislators about changing the legally-defined relationship between midwives and physicians, how the legal definition of that relationship impacts affordable maternity care and why improving the nature of the relationship btw midwives and physicians is in the interest of taxpayers and the State’s ability to meet its financial obligations.

This new language, which so nicely re-frames such a complex and loaded topic, is a real gift to midwifery. I hope everyone who speakers on behalf of our legislative efforts will take advantage of this improved way to discuss a topic that has been off-putting for Legislators in the past. Proof of that statement is our legislative record. This is the 5th legislative attempt to (a) replace physician supervision OR (b) change the relationship between midwives and physicians.

Plan A — counting all our legislative and regulatory attempts, ‘getting rid of supervision’ language has failed us 5 times in a row

Plan B — we’ll soon see, but I think focusing the conversation on:

• affordable, cost-effective maternity care
• the economic advantages of physiological childbirth practices
• eligibility by midwives to serve low-income women
• changing the relation btw midwives and physicians

This is our ticket to ride and this time, we ARE going to do it!

Gender-specific vs. gender-neutral talking points

In 1982, I and other members of the San Francisco Valencia Women’s Center flew on the same plane as Gloria Steinem to Chicago to participate in a day-long rally and march to get the Equal Right Amendment passed. Its been 31 years and still no ERA.

I’m suggesting that we re-think our strategies, particularly our perspective on who midwives need to reach. Speaking to women, mom, dads, birth educators, breastfeeding groups, etc. to generate support is very different than ‘speaking legislator’. Conversations about ‘access to care’ and the ability of childbearing women to choose midwifery are both important topics. But unfortunately, women’s issues don’t do particularly when measured by legislative success.

However the communication problem doesn’t stop with the Legislature, which means our outreach can’t be restricted by age, gender, economic status or interest in childbirth per se. Everybody is the answer to the query “who should we appeal to?”

So when I talk of the ‘affordability’ issue in affordable maternity care, I’m particularly referring to those who pay the bills. Except for the statistically rare woman who pays out-of-pocket for a midwife-attended home birth, over 90% of the money that goes for maternity care in the United States does NOT come from the bank account of the pregnant woman or her family. In California 40% is paid by AIM and the State’s MediCal program and most of the rest comes from employee health insurance plans or flexible (medical) spending accounts.

By providing less medicalized and a more supportive and personalized kind of maternity care to healthy women, the number of premature births is greatly reduced and the Cesarean rate drops from over 30% to under 10%. Legislators should care about that and if they don’t already, its our job to educate them.

The California Legislature is still facing a huge budget deficit. In regard to affordable maternity care, its members need to appreciate some really simple math:

every dollar of unnecessary and unproductive expense paid out by MediCal is a dollar NOT available to pay for road repairs, support our community college system, fund pre-K education or provide substance-abuse treatment programs for teens and young adults (those who attended the March 11th hearing will appreciate the urgency of this last category)

The contrast between spending money on the complications of surgical deliveries (including necrotizing faciitis) and hiring more teachers and firefighters and putting ‘dirty doctors’ who run prescription pill mills out of business is quite powerful.

A perspective that is less gender-centric and less age-related takes a topic that otherwise interests only a small segment of society – midwives and families interested in ‘alternative’ childbirth practices — and makes it an issue of great importance to every man, woman and child in the state of California, as well as the environment and our wildlife. Even our animal shelters benefit when the tax base is sufficient to meet our public needs.

When it comes to the money, everybody has a dog in this fight, which means everyone benefits by changing the relationship between midwives and physicians.

By changing the legal definition of that relationship to one that is more appropriate for the 21st century, midwives who wish to can qualify as MediCal providers for low-income woman. Families with health insurance can get reimbursed for services received from their midwife. Affordable maternity care means that taxpayers will get library services, school buses, crossing-guards and be much happier with their legislators.

My request is the same as always ~ do a little something everyday to further the political action.

• Contribute $$
• Volunteer to help CAM
• Become better informed
• Write, call or visit legislators
• Create a unique action-plan in your peer-review or regional group
• Read & share the info in March 4th TIME Magazine article “BITTER PILL”
• Post your thoughts, ideas, news or video about our legislative efforts on Facebook
• Interview/video a midwife, mother or other person who has compelling story or a good idea
• Volunteer to read the information posted on this website about the background of these political issues
• Send an article about any of these “affordable maternity care” topics to your company newsletter or local newspaper
• Write a script for a documentary about history, politics, legal, & legislative issues pertinent to our current legislative efforts

Material posted about our current legislative efforts begin on February 17th, 2013. If you go to “New Posts”, then scroll to the very bottom of the webpage, there are short excerpts and links to earlier posts and back-arrows to access older dates.

Readers vs. Activists:

If you are more of a reader than a writer, trying reading the new material I post on the website every day of two . When you see something you think is important or interesting, copy it into an an email and send it to other midwives or the CAmidwives Yahoo group. You could buddy up with one of CAM’s busy officers, who are in a chronic state overwhelm. Constance is the current CAM president and is tying to maintain a mfry practice in addition to becoming a nearly full-time lobbyist. Sara Davis is in addition nursing a 7-month out baby. I’m sure other CAM Board members are working just as hard and are just as busy. Consider contributing your time as read and personally alert your identified person if you see something — an idea or information — that you believe she should know about.

If you read enough of this stuff, you will join me in being an Idiot Savant on midwifery politics in California!

link back to part 2-a

Our current model of maternity care for healthy women is the product of the historical events already recounted in this document.

Over the last 50 years the rate of medical and surgical interventions in normal childbirth has climbed steadily without a comparable improvement in outcome. Each decade new ideas, new drugs, new technologies are added, while the encrustations of previous decades are preserved as the foundation of “customary care” and a hedge against claims of medical malpractice. All indicators point to the indefinite continuation of this trend.

Obstetricians are generally satisfied with their modern role, which is to supervise the endless convey belt of childbearing women. Under their authority, each laboring woman is cared by a variety of nurses acting under ‘doctor’s orders’. The job os these hospital employees is to dutifully administer many drugs and employ different kinds of medical devices.

Modern L&D nurses are forced to become specialists in managing electronic fetal monitors, a technology that is both central to the medical management of modern childbirth care and like a baby (or a beta product) constantly in need of being ‘tweaked’ in order to work properly. The L&D staff often spends more time ‘nursing’ the EFM than the mother-to-be.

All of these medical activities are an effort to ‘cure’ laboring women of pregnancy as quickly as possible, via the use all means possible, including Cesarean section. Of course, the one exception is providing physiologically care and one-on-one support by the mother’s primary birth attendant.  A popular obstetrical journal published a comment by an obstetrician in 1992 that clearly identifies the past, present and future direction of the obstetrical profession in that regard:

“It is no longer feasible for individual physicians who have invested 12 years in training at a cost of hundreds of thousands of dollars to dedicate extended periods to observing one normal woman in labor.” [Macer JA et al; Am J Obstet Gynecol 1992:166:1690-7].  

Since the early 1970s, the Cesarean section rate has risen from 5% (1 in 20)  to 32.8% (1 in 3). This high C-section rate is associated with a relative increase in maternal deaths associated with the immediate, delayed and long-term complications of this major abdominal operation.

The most costly interventions and those most associated with iatrogenic and nosocomial complications are:

• continuous electronic fetal monitoring in low and moderate-risk pregnancies
• induction of labor as a pre-emptive strategy based solely on due-dates, convenience or other non-medical reasons
• liberal use of Cesarean section in healthy populations of childbearing women

The well-known and highly respected Maternity Center Association of NYC has been serving low-income women and lobbying for safe and affordable maternity care policies since 1918. Recently renamed “Childbirth Connection” , this advocacy organization conducted a series of surveys called “Listening to Mothers” in 2002, 2004 and 2006.

Their researchers interviewed essentially healthy women who had normal term pregnancies (no medical complications or prior C-sections, no breech babies, twins or premature births) to determine the quality of care these women received, number and frequency of interventions and the level of satisfaction with the type of maternity care received. Thousands of new mothers filled out lengthy questionnaires that provided a snap-shoot of how the 1910 plan for the universal medicalization of normal childbirth was working out for the pregnant women who continue to give birth under its ministrations.

According to “Listening to Mothers” data, this 100-year old model of obstetrical care for healthy women has become even more medicalized as we’ve gone through time.  Typically a normal labor and birth in women with no prior medical issues for mother or baby includes seven or more medical or surgical interventions. In this survey approximately 70% of these healthy childbearing women reported some form of surgical procedure or operative delivery — episiotomy, forceps, vacuum extraction or Cesarean surgery.

Continuous electronic fetal monitoring (EFM) was introduced in the mid-1960s. Obstetricians hoped this new technology would provide them with an early warning system that could prevent babies from developing cerebral palsy. By 1980, continuous monitoring had become the standard for all women in labor. EFM is billed at $400 an hour and used in 93% of all hospital labors, even though all the studies ever conducted on the routine use of EFM in normal pregnancies were unable to confirm any improved outcomes for either mother or babies.

The only  consistently documented effect of EFM was an increased rate of Cesarean surgeries.

Despite the significant additional expense of continuous monitoring, EFM has been unable to lower the CP rate by even the tiniest smidgen. This was officially acknowledged by the obstetrical profession nearly a decade ago, when they published materials stating these facts for the purpose of providing a dissenting opinion in malpractice cases based on EFM strips that claim to prove that the obstetrician’s failure to perform a ‘timely’ Cesarean caused their baby’s cerebral palsy.

Nonetheless, EFM remains a mainstay of obstetrics. Hospital risk managers continue to insist that the printout or electronic record of EFM tracings is their best defense in case of a malpractice suit. However, billing 93% of one’s laboring patients at $400 an hour for their entire labor (as much as 48 hours for women being induced) may be part of the incentive to preserve this tradition.

Labor induction rates have likewise sky-rocketed. This is often a two-day medical procedure, especially for first-time mothers, and is associated with increased Cesarean rates. Many hospital obstetrical units have a policy known as “Pit to distress” — that is, a protocol to intravenously administer the hormonal drug Pitocin (it induces or speeds up labor) in increasingly large doses until the mother either delivers vaginally, or the baby goes into fetal distress and has to be delivered by emergency Cesarean section. Personally, I consider “Pit to distress’ to be a criminal practice of medicine.

In 1996, the Cesarean rates in the US were 20.7 percent. Having risen from 5% in 1970, a 21% C-section rate was consider by many to be scandalous. This triggered much handringing and debate about how control our out-of-control surgical delivery rate. That same year,  the Medical Leadership Council, which is an association of over 2,000 hospitals in the US) concluded that our cesarean rate was:

 “medicine’s equivalent of the federal budget deficit; long recognized as [an] abstract national problem, yet beyond any individual’s power, purview or interest to correct.”

“..beyond any individual’s power, purview or interest to correct” was a prophetic observation, as Cesarean delivery is now the most commonly performed surgical procedure in the United States, and it numbers continues to increase annually. C-section is also the most common operating room procedure performed among all patients in US hospitals.

This last number is even more chilling, as it describes diagnostic procedures. These are not surgeries at all in the since of an operation, but merely the use of technology under sterile conditions. Examples are angio-catherizations and similarly ‘invasive’ radiology procedures. This number means that more healthy women are having major abdominal surgery than elderly and ill patients who need diagnostic procedures.

The Cesarean rate reached an all-time high in 2011 of 32.9 %. Today it is essentially unchanged at 32.8%. Some American hospitals have a 69.9 percent rate (i.e., 70%). The  per-hospital mean rate for annual Cesarean surgeries performed is 1,378.  But of the 593 hospital studied,  270 American hospitals perform an average of 11,971 C-sections every year. That’s a 1,000 Cesarean surgeries a month, which is 250 a week or 35 cesareans a day. The surgical delivery rates between hospital varies by ten — from 7.1 percent to 69.9 %. However  there was a fifteen-fold difference cesarean rates for women with lower-risk pregnancies. In many hospitals,  36.5% of their healthy pregnant women have their baby delivered by major abdominal surgery.

When compared to similar countries worldwide, the US cesarean rates exceeds them without any measurable clinical benefit. A recently published study on the inter-hospital variations in C-section rates noted that the vast differences between hospital is not primarily based on maternal-fetal health issues, but are instead the result of practice patterns, that is, physician preference and/or hospital policies. The study concluded that “practice patterns” are “driving the costly overuse of cesarean delivery in many US hospitals”.

Surgical delivery is twice as expensive as normal birth, and is associated with increased rates of very serious sometimes fatal complications — hemorrhage, emergency hysterectomy, infection, anesthesia complications, stroke, cardiac failure, blood transfusions, prolonged care in the ICU.

This makes maternity care the number one generator of income for hospitals and hands-down winner of the lottery for subverting the idea of healthcare for people that have medical needs into a ‘profit center’ for acute-care institutions.  Since Medicaid pays for nearly half of US births in the US, this had created a tidal wave of wealth transferred annually from taxpayer to the hospital industry.

These shocking high numbers and dubious practices are apparently what happens when a large, complex and expensive system enjoys “regulatory capture” for an entire century. Some people point to this as a medical monopoly. In modern times, this same unbridled entity has successfully avoided transparency as hospitals and doctors don’t generally have to publish their practices or their medical-surgical intervention rates. They also have no public oversight of their quality of care, and they have no accountability for outcomes except fiduciary issue that affect executive pay or shareholder value.

Nice work if you can get it.

Topic continues ~ part 3 ~

Link back to part 1: 

In 1910 influential obstetrician declined to consider the other excellent models of care available at that time. One of the biggest hindrance to these other options was a systematic bias against women as healthcare practitioners.  The other was their desire to re-invent obstetrics as a stand-alone surgical specialty, which clouded their objectivity.

These doctors were not ill-intentioned, just a product of an era that had strict class and gender lines. In American, midwifery was on the wrong side of both.

While these doctors were mortified that many European countries had far better outcome statistics than the US, they weren’t willing to consider the excellent model used in Sweden since 1881, or even ask why they consistently had better outcomes and dramatically lower rates of maternal mortality than the US.

In 1900, Sweden’s MMR was 200 maternal deaths per 100,000 in 1900, while 665 new mothers died per 100,000 live births for the same period in the United States. The already huge disparity between the US and Europe continued to climb steadily  and by 1925, there were 1,200 maternal deaths annually per 100,000 — a 6-fold difference.

What was Sweden’s big ‘secret’? Nothing special or different from other European countries — they maintained a public health system that included a large number of well-trained profession midwives. These women practitioners provided maternity care as independent practitioners, consulted with general practice physicians when they needed advice, and called on them whenever their patients needed medical care.

In 1881 Sweden passed national laws that required all of its midwives and physicians to learn and scrupulously use the newly-discovered principles of asepsis and appropriate sterile technique when attending births and caring for new mothers and new babies.

Other European countries had similar midwife-centric maternity care systems and laws on aseptic technique, but somehow Swedish midwives, working in a supportive and mutually-respectful partnership with their country’s doctors, seemed to do it best.

But in America, strict gender roles, gender bias and gender discrimination were ubiquitous and fully lawful. This was particularly unfortunate in the context of midwifery, as the maternal-infant mortality statistics for midwife-attended births were consistently and substantially better than those of physicians.

Oddly enough, the obstetrical profession acknowledged this, but then explained away its relevance. First they said midwives delivered more women who had given birth before (multipara), which generally have shorter labors and easier births, while MDs were convinced that they attended a disproportionally higher number of first-time mothers (primipara), which were more likely to have longer labors and develop complications.

The other explanation for the better outcomes of midwives as contrasted with physicians was attributed to the poor quality of medical education for American doctors when compared to Europe. European medical schools provided its med students with lengthy and high-quality clinical training that required them to deliver a minimum of 20 childbearing women under strict supervision by their professors.

In the US, minimum medical training in the management of normal childbirth consisted of merely watching one’s professor deliver 6 laboring women.  When these new doctors set out to practice, it was customary for them to use forceps and perform any other childbirth-related surgical procedures even when they had absolutely no hands-one training in medical school, never seen the procedure performed as a medical student, and had zero prior experience.

The reasoning of these obstetrical leaders was simple: If  “uneducated” midwives (their words) could to do a credible job without having attended medical school, then surely improved medical education, with additional clinical training and hand-on teaching of advanced surgical skills, would produce doctors who could work circles around midwives.

It was assumed that such superior skills would allow MDs to effortlessly manage normal childbirth and successfully deal with any complications that might develop. This new crop of better educated physician-surgeons would easily render the profession of midwifery totally obsolete and ultimately irrelevant.

Best of all, the systemic removal of midwives from the “the birth business” (their words) freed up what was referred to as “obstetrical material” — that is, teaching cases or the much coveted clinical material. By eliminating midwives, poor women would have no option but to come to teaching hospitals, where their births would become ‘material’  for the improved clinical training of medical students.

This was applauded as a win-win for women, who would receive the new medicalized (thus superior) form of care, and medical students, who would receive a superior medical education — all made possible through the elimination of midwifery.

The official plan in 1910 was to temporarily tolerate midwives who provided care to the very poor — mainly immigrant and minority populations who couldn’t afford to pay the much larger professional fee for an MD-attend birth. However, this forbearance also included a plan to use legal and legislative methods that would eventually eliminate the lawful practice of midwifery in the United States.

In the meantime, leaders in the obstetrical world were busy making arrangements with the Carnegie and Rockefeller foundations and other charitable and philanthropic groups. The obstetrical profession was urging them provide an alternative to midwives by financing clinics that provided free or very low-cost maternity care to poor pregnant women. These women would  them be instructed to go to a particular local hospital when they went into labor.

These charitable foundations would then pay the full professional fee of public-spirited physicians who graciously volunteered to cared for these charity cases and attended their hospital births. Of course, the hospitals also appreciated the guaranteed additional business that was part of these arrangements. A few obstetricians with an eye to the future boldly envisioned a time when this private philanthropic function would be taken over state and local governments, and in the interest of public safety, a program for low-income women would reimburse MDs out of taxpayer funds for attending medically-indigent maternity patients.

Having so throughly undermined midwifery as an independent profession, the obstetrical world assumed there would soon be no need for midwives anywhere in the United States and childbirth services would be the sole domain of the obstetrical profession. This goal was easily achieved during by the 1950s. Both the public and medical world celebrated the ‘elevation’ and professionalization of maternity care by physician-surgeons who the mind’s eye  provided care in sparkling clean antiseptic hospital wards, while surrounded by smiling faces of happy healthy women holding their adorable new babies.

What was behind the “No Admittance ~ Authorized Personnel Only” sign on double doors to the L&D suite?

What the public did not see was rows of women laboring under the influence of Twilight Sleep who were struggling against the 4-point leather restraints used to keep them from falling out of bed and hurting themselves — the natural result of the hallucinations caused by the drugs they’d been give. They also didn’t see doctors delivering the depressed babies of women who been drugged senseless with narcotics during labor, and now were unconscious under general anesthesia.

No one except L&D nurses such as myself were allowed to present when the doctor performed the typical ‘generous’ episiotomy or listen to the echo of blood fall in a stream like an open facet  into the empty stainless-steel bucket 30 inches below the mother’s buttocks. No one but me and the other nurses knew that doctors routinely instructed L&D nurses to provide an extremely brutal and dangerous form of fundal pressure, which meant pushing with one’s entire weight on the top of the mother’s uterus, to thrust the baby down in the mother’s pelvis while the doctor pulled  from below with forceps.

After a few hair-rasing minutes of this, the doctor extracted a limp baby with forceps and then handed the respiratorily depressed baby to the nurse to resuscitate. Turning his attention back to the new mother, he reached them his gloved hand and arm up into her uterus to manually remove the placenta.

This private drama ended when the doctor sutured the episiotony incision and finished with what was called “the husband stitch”. Apparently one of the obstetrician’s professional duties at that time was to be sure the husband had no reason later to claim that after the baby was born, “having sex with my wife is like walking into a warm room”.  A happy husband was obviously important to the obstetrical profession.

As for the mother, her baby would be sent to newborn nursery so her husband and other family members could enjoy looking at their newborn lay under a warming light for the next 12 hours.

The mother herself would be unconscious or groggy for hours more, while being cared for by nurses the recovery room. Eventually she would rouse enough to ask ‘What did I have?” The nurse would happily inform her that she had a girl (or a boy). Then the groggy mother would fall back into her stupor for another hour or two.

Topic continued ~ part 2-b ~Impact of these historical events on taxpayers, state budgets and the federal deficit: (link right below on this page)

link back to: “Dr. Bishop tells our story for us — why doctors need to have supervision removed from the LMPA”

Editor’s Note: Eventually I will add a bibliography with links from this post to the supporting documents, as well as stand-along excerpts from exceptionally informative resources, such as the results of the 3 different “Listening to Mothers” surveys by Childbirth Connection (formerly Maternity Center Association of NYC).

The problem of affordable maternity care for childbearing families and the taxpaying public starts with the lack of access to physiologically-based care during pregnancy and childbirth for healthy women. I know that ‘physiological’ is a long word, and unclear concept, but if you just think of this as ‘normal care for normal birth’ you can’t go wrong.

Unlike many other developed countries, healthy pregnant women in the US are primarily cared for by physicians trained in the surgical speciality of obstetrics, instead of family practice physicians and professional midwives. Countries with low rates of medical intervention for normal childbirth generally provide low-tech, high-touch maternity care. In this model the most frequent birth attendant  is a professionally-trained midwife who is providing care within the mainstream healthcare system.

Not only is this a far more cost-effective system, but these countries also have much better maternal-infant outcomes. The connection between cost-effective, hands-on care and better outcomes is not a new phenomenon. These same European countries had dramatically lower rates of maternal-infant mortality as far back as 1900*.

However, this model of affordable, maternity care was the road not taken in America. As a result, a cost-effective maternity services were not, and still are not, a normal part of the healthcare system in the United States. Instead Americans, including California residents, spend more on maternity services any other country (more than double), and still have dismal maternal-infant outcomes — we rank 42nd in maternal deaths and 50th for infant mortality.

This is a peculiarly American problem that developed over the last hundred years. During the early 1900s the medical profession didn’t fully understand which childbirth practices reliably made things safer, and which had serious side-effects that increased the frequency  and seriousness of complications.

Compared to other developed countries, maternal and infant mortality rates in the US were shockingly high during this era, with at least 10,000 new mothers dying every year (MMR 1910). During the pre-antibiotic era of early 20th century maternity care,  3 times more mothers died in the US than in Western Europe (200 vs. 675 per 100,000 live births). This embarrassing international situation had both the public and the medical professional looking for an immediate solution.

Unfortunately the abilities of medial science in 1910 were still very rudimentary.  It would be another 40 years before antibiotics were discovered. Doctors were not yet able figure out which women and which pregnancies were high risk, as many modern diagnostic tests and ultrasound imaging had not yet been invented. For pregnant women with Rh-negative blood types there was no way to eliminate the potentially-lethal complications for their unborn babies. There were still no safe blood transfusions for women with other serious medical complications. Safer anesthetics and better surgical techniques weren’t available until after World War II.

Given the limitations of medical science, the experts of the time concluded that the best way to reduce maternal mortality was to dramatically change the way the medical profession treated normal childbirth. Their recommendation was a highly-medicalized system of obstetrical care to be uniformly applied to the entire childbearing population — healthy women as well as those with medical problems.These grand ideas were dramatic and bold, as well as drastic in their effect AND magnitude, affecting over 2 million mothers-to-be every year and represented the most profound change in childbirth practices in the history of the human species.

These policies called for the elective hospitalization of laboring women. However, the hospitalization of maternity patients on a large scale introduced its own problems. During this pre-antibiotic era (prior to 1937) the leading cause of death in new mothers was infections — childbed fever (i.e. puerperal sepsis). Without access to antibiotic drugs, this one complication caused  a third of all maternal mortality.

The vast majority  of these deaths from sepsis occurred in hospitalized maternity patients. In the very early 1900s, hospitals had a very bad reputation and were seen as places of last resort. The majority of hospitalized maternity patients were homeless, mentally ill, petty criminals or very poor who couldn’t pay a doctor or midwife to provide care in own their home. Medically-indigent women received free care in teaching hospitals by agreeing to become ‘clinical material’ for medical students. People of means avoided hospitals like the plague (bun intended).

To make this new plan work, the obstetrical profession had to address the bio-hazards and contagion that naturally occurred whenever large numbers of childbearing women were aggregated together. Influential obstetricians decided the most effective method for preventing the spread of puerperal sepsis to treat normal birth as a surgical procedure. That meant the same sterile protocols that doctors used when performing abdominal surgery. The obstetrical profession was confident these new protocols would eliminate, or at least dramatically reduce, the majority of potentially-fatal birth-related  infection.

The principles of aseptic technique and surgical sterility were originally developed in England by Dr. Joseph Lister in the 1870. For obvious reasons, “Listerization” referred to the use of these protocols.  In order to Listerize normal childbirth, the very last few minutes of 2nd stage labor (when the baby was expected to be born very soon) was re-defined as a surgical procedure to be performed by physicians. This surgical activity was re-named the “delivery” and provided with a surgical code used for billing and the daily hospital census.

These new childbirth practices included the routine use of ‘Twilight Sleep” during labor. Women were given a injections of narcotics for pain and the amnesic-hallucinatory drug scopolamine to block the mother’s memory of the labor. Administration of these drugs was repeated every few hours until the birth was imminent.  At that point general anesthesia (ether or chloroform) was used to render the mother unconscious during the surgically-conducted delivery. This consisted of a series of surgical procedures that included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the perineum.

Doctors of that era expected the pre-emptive use of these medical and surgical interventions to dramatically and permanently reduce birth-related complications, resulting in a vastly improved mortality statistics. For the first time, the United States would be on a par with England and other comparable European countries.

These unprecedented changes in childbirth practices were the product of a remarkable different decision-making process than we are use to today. Modern standards for implementing  untested medical treatments or new policies are generally based on scientific research.

But in the early 20th century, the concept of evidence-based medicine (EBM) did not yet exist. At that time the general standards for new forms of medical care were based on the opinion of medical experts — in the case, influential obstetricians of that era.

It is a mere happenstance of history that modern obstetrics in the United States developed during the first half of the 20th century, in a pre-antibiotic world that lacked so many of technologies we think of as “modern medicine”.  As a direct reflection of this experience our modern model of obstetrical care was molded by the grim realities and 19th century thinking they produced.

This kind of thinking both rejected physiologically-based care for normal childbirth (they claimed birth was intrinsically pathological) and abhorred the practitioners that provided it – midwives. The intrinsically fearful attitudes it spawned turned healthy childbearing women into the patients of a surgical specialty, labor into a potential medical emergency, and normal childbirth into series of surgical procedures ‘performed’ by physicians in hospitals.

Our modern system has dutifully maintains all these traditions, and added undreamed of interventions, dozens more medical treatments, encourages the casual use of surgical procedures and the ‘normalization’ of Cesarean surgery as an equally safer and therefore a better way to have a baby, since it saves the mother and baby the time and trouble of having to labor.

This system systematically attempts to control midwifery our of existence, and when that doesn’t work, to be as adversarial and uncooperative as possible. The legacy of it all is an unaffordable, not cost-effect, not safe system that significantly affects childbearing families, midwives, taxpayers, state budgets and the federal deficit.

Topic continued ~ part 2-a ~ The impact of these new policies on the historic profession of midwifery in the US (link right below)