Letter to Elected Officials in Support of MOMS

Dear Congressman Buchanan, Senator LeMieux, and Senator Nelson:

Something monumental and potentially life-saving for America's mothers and babies happened last week on the House floor. Congresswoman Lucille Roybal-Allard introduced the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act (HR 5807), which places a national focus on evidence-based maternity care practices to help achieve the best possible maternity outcomes for mothers and babies. Your Florida colleagues in the House, Congresswoman Debbie Wasserman-Schultz and Congresswoman Kathy Castor, have co-signed this legislation. I am writing to implore you, as a mother, as a taxpayer, as a maternal rights advocate and as your constituent, to sponsor this act.

I have written you before to tell you that the United States currently ranks 41st in maternal mortality, yet we spend significantly more on childbirth than any other industrialized country. Moreover, our nation's 32% c-section rate, high premature birth and labor induction rates, and their subsequent repeat admission rates are all playing a major role in our nation’s escalating health care costs. Hospitalization related to pregnancy and childbirth costs approximately $86 billion each year, the highest hospitalization costs in any area of health care.

The MOMS for the 21st Century Act responds to this crisis by creating a new Health & Human Services focus on the promotion of optimal maternity care, an additional focus area for the Office on Women's Health, and an Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes, a widespread consumer education campaign, and a bibliographic database of systematic reviews for care of childbearing women and newborns. Most importantly, it calls for accountability in accurate research and data collection, and the enhancement of an interdisciplinary maternity workforce, including Obstetricians, Certified Nurse-Midwives, and Certified Professional Midwives.

“The MOMS for the 21st Century Act makes overdue reforms to our nation’s maternity care system to better ensure that providers and mothers have the best information available when making serious maternity care decisions,” Congresswoman Lucille Roybal-Allard said last week. “The fact is we have a maternity care system in the United States that has not traditionally adhered to evidenced-based practices. For example, there is widespread over use in our country of maternity practices, such as elective Cesarean sections and scheduled inductions. These procedures are beneficial and needed only in limited situations. When used routinely and indiscriminately and without medical necessity, these and other practices expose women and infants to unnecessary risks at high cost. On the other hand, credible science-based research tells us non-invasive maternity practices...produce considerable improvement in maternity outcomes, such as healthier moms and babies. Yet these cost-effective evidence-based practices, which have no detrimental side effects, are significantly underused in our country.”

As a consumer, I will do everything possible to offer you the utmost support from my community in sponsoring the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act (HR 5807). I look forward to hearing your response on this issue and will follow up with your legislative aides by telephone. Thank you for your service and your attention.

Hopefully,

Laura Gilkey, mother of two

Sarasota, Florida

The MOMS Act: Maternity Care Reform!

The very next day after the refreshing revision to ACOG's VBAC guidelines were released, my new favorite Congresswoman Lucille Roybal-Allard (D-California) introduced the MOMS (Maximizing Optimal Maternity Services) for the 21st Century Act on the House floor. Special thanks to Kathy Castor (D-Florida) for co-signing the legislation (Ms. Castor has been vocal in our own state about the correlation between our high c-section rate and premature birth). This has been a very exciting week along the path to healthier American birth! The following is from Congresswoman Roybal-Allard's office, describing her reason for the introduction and what she hopes it will achieve (including accountability for data collection, interdisciplinary maternity care including midwives, pregnancy and labor support including doulas and nutrition education, and more).

The United States spends significantly more on childbirth than any other industrialized country, but ranks far behind almost all developed countries in healthy child birth results for both mothers and babies. To address this national tragedy, Congresswoman Lucille Roybal-Allard introduced the Maximizing Optimal Maternity Services for the 21st Century Act which places a national focus on evidence-based maternity care practices to help achieve the best possible maternity outcomes for mothers and babies.

“Each year, more than 4 million women give birth in the United States. Caring for them and their babies plays a major role in our nation’s escalating health care costs. In fact, hospitalization related to pregnancy and childbirth costs approximately $86 billion each year, the highest hospitalization costs in any area of health care. Tragically, in spite of all the money we spend, the United States continues to rank far behind nearly all developed countries in perinatal outcomes, with childbirth continuing to present significant risks for mothers and babies, particularly in communities of color,” said Congresswoman Lucille Roybal-Allard, who co-founded the Congressional Study Group on Public Health and chairs the Congressional Hispanic Task Force on Health. “The MOMS for the 21st Century Act, which I introduced, addresses these disparities in our nation’s maternity health care system by making key reforms to improve the health and well-being of mothers and their babies in our country while bringing down maternity care costs.”

The Maximizing Optimal Maternity Services for the 21st Century Act (HR 5807) creates a national focus on maternity care by establishing an Interagency Coordinating Committee charged with promoting medical practices proven to provide the healthiest results for mothers and babies. The legislation authorizes a public awareness media campaign to educate the public about the best-proven maternity care practices. The legislation expands federal research on best maternity practices. The bill also authorizes data collection to pinpoint specific geographic areas of the country that lack maternity care providers.

Finally, the measure puts in place a concerted effort to create a more culturally diverse and interdisciplinary maternity care workforce. It establishes loan repayment programs for providers in maternity care shortage areas. It authorizes grant programs for maternity professional organizations to recruit and retain minority providers. It also calls for the development of core curricula across maternity professional disciplines to better ensure that providers are better trained and able to inform patients about all of their maternity care options.

“The MOMS for the 21st Century Act makes overdue reforms to our nation’s maternity care system to better ensure that providers and mothers have the best information available when making serious maternity care decisions,” Congresswoman Lucille Roybal-Allard said. “The fact is we have a maternity care system in the United States that has not traditionally adhered to evidenced-based practices. For example, there is widespread over use in our country of maternity practices, such as elective Cesarean sections and scheduled inductions. These procedures are beneficial and needed only in limited situations. When used routinely and indiscriminately and without medical necessity, these and other practices expose women and infants to unnecessary risks at high cost. On the other hand, credible science-based research tells us non-invasive maternity practices such as prenatal smoking cessation programs and centering of pregnancy group prenatal care, produce considerable improvement in maternity outcomes, such as healthier moms and babies. Yet these cost-effective evidence-based practices, which have no detrimental side effects, are significantly underused in our country.”

A longtime advocate on behalf of mothers, infants and children, the congresswoman has been honored by the March of Dimes and the Association of Maternal and Child Health Programs. Both awards recognize the congresswoman’s authorship of the Newborn Screening Saves Lives Act, which was signed into law in 2008. Enactment of the Newborn Screening Saves Lives Act established national newborn screening guidelines intended to make comprehensive newborn screening widely available throughout the country. The law also provides federal funding to educate parents and health care professionals about the importance of newborn screening, and improves the systems for follow-up care for infants identified with an illness through the newborn screening tests. In addition, the law requires the Centers for Disease Control and Prevention to ensure the quality of laboratories involved in newborn screening, and establishes a system for collecting and analyzing data that will help researchers develop better detection, prevention and treatment strategies.

Amnesty International Executive Director Larry Cox issued the following statement in support of the "MOMS for the 21st Century Act," introduced Wednesday evening in the House of Representatives by Rep. Lucille Roybal-Allard, (D-CA):

"Amnesty International commends Rep. Roybal-Allard for her commitment to improving the outcomes and disparities in maternal health in the United States. Access to good quality maternal health care is a right, not a privilege. It is shameful that as a nation we have neglected this right for so many women for so long. Amnesty International is grateful for Rep. Roybal-Allard's leadership and her recognition of the terrible human cost of this failure. We stand behind this significant legislative effort to ensure that all women have access to the maternal health care they need.

"The "MOMS for the 21st Century Act," if passed, will require the U.S. government to live up to its obligation to address this problem by developing a coordinated approach to maternal care that will improve women's access to quality, evidence-based care and will begin to address maternal health disparities. This is a first step to reducing the needless loss of women's lives that tragically affect so many families in the United States and preventing the complications that have risen steadily for decades.

Normal Birth at a Local Science Museum

Yesterday I visited Tampa's Museum of Science and Industry (MOSI) with my children and our friends. When we arrived at the "Amazing You" human body exhibit, I was greeted by the statue of a pregnant woman who, albeit notably missing some anatomical details, was portrayed as a loving mother. I was optimistic.

One of the first displays we came to was a video booth with four options: stages of labor, normal birth, cesarean delivery and birth of twins. While time and children did not permit me to watch all four, I wanted to at least view this institution's idea of normal birth. Overall, I was very pleased. Sure, the woman giving birth was in the hospital standard lithotomy position, and I can assume from her demeanor that she was given epidural anesthesia, and there was a lot of manual obstetric manipulation happening during the pushing stage--but the mother and father were alert, present, and afterward, they described their experience as euphoric.

When the baby in the video was born she was placed immediately on her mother's chest. The cord was clamped a bit early, but the care providers encouraged breastfeeding (successfully) right away. I left the video booth pleased that the young women visiting MOSI would view this rather gentle birth experience with a sense of normalcy. There was absolutely no fear embedded into the piece.

But then I saw this daunting tunnel in the kids' play area. The Birth Canal Challenge was dark, angular and menacing--albeit intended in good fun, I couldn't shake their implication that birth was an intrinsically dangerous event.

So while we are coming a long way, there is still an undertone of fear in our society surrounding birth. I have read its evolution and understand its roots, yet I feel it is time to replace it with trust, love, knowledge and information.

ACOG Revises VBAC Guidelines

Tonight, women with cesarean section scars and their advocates are celebrating no small victory. The American College of Obstetricians and Gynecologists (ACOG) has issued today a revision to their guidelines for Vaginal Birth After Cesarean (VBAC), including the endorsement of trial of labor for most women with one cesarean, some women with two cesareans and some women carrying twins. The revision also states that even if an institution does not offer trial of labor after cesarean (TOLAC), a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor. The news is already beginning to trickle into the right places to reach most pregnant women (i.e. WebMD) and I can only hope its recommendations will begin to increase the single digit VBAC percentage, a must in reducing our nation's cesarean epidemic. The press release from ACOG follows in its entirety.

Ob-Gyns Issue Less Restrictive VBAC Guidelines

Washington, DC -- Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and Gynecologists.

The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.

"The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

In keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago.

VBAC Counseling on Benefits and Risks

"In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful. A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).

Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.

Uterine Rupture

The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.

"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."

Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.

The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center.

Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is published in the August 2010 issue of Obstetrics & Gynecology.

CIMS Responds to Skewed Homebirth Study

The following is republished with permission of the Coalition for Improving Maternity Services, an organization committed to mother-friendly childbirth and endorsed by over 1,200 organizations and individuals, including myself.

Raleigh, NC (July 9, 2010)-The Coalition for Improving Maternity Services (CIMS) is outraged that the publishers of the American Journal of Obstetrics and Gynecology (AJOG) accepted a poorly designed and methodologically unsound study in which authors concluded there is a 3-fold increase in neonatal mortality in planned home births compared with planned hospital birth.

"In our analysis of multiple studies from countries worldwide," stated CIMS Chair Michelle Kendell, MBA, AAHCC, "CIMS found that the authors of the study included confounding data, such as outdated and low-quality studies, low-risk and high-risk mothers, babies born preterm, babies unintentionally born at home, births attended by unqualified providers, and data from birth certificates that researchers have found to be notoriously inaccurate."

Although the authors acknowledged that most of the articlesreviewed had similar outcomes of low neonatal mortality, they based their conclusion on statistics drawn from questionable and poor quality studies.

Furthermore, the study's lead investigator Joseph R. Wax, MD, and his co-authors inexplicably eliminated the only high-quality study of planned homebirths in the U.S. that showed excellent health outcomes for infants and their mothers when attended by certified professional midwives. (Johnson & Daviss BMJ 2005).

In a press release, the American College of Nurse-Midwives, a CIMS Organizational Member, reported, "the authors' conclusion differs significantly from findings of many recent high-quality studies on home birth outcomes which found no significant differences in perinatal outcomes between planned home and planned hospital births."

Other research conducted by the CIMS Expert Work Group found that planned home births with a qualified care provider resulted in similar, not greater, perinatal mortality rates compared with a similar low-risk population of women having hospital births, despite lower intervention rates, including electronic fetal monitoring, use of IVs, pain medication, instrumental deliveries, and cesarean sections.

Lamaze International, a CIMS Organizational Member, also questioned the study's conclusion. Amy Romano, MSN, CNM, researcher and contributor on Lamaze International's Science & Sensibility blog, wrote, "high quality studies, conducted in low-risk women in integrated maternity care systems, find no excess risk for babies and significant benefits for mothers."

The Centers for Disease Control (CDC) reports that babies born at home are less likely to be born preterm and low birth weight compared to babies born in the hospital.

Mary Lawlor, CPM, president of the National Association of Certified Professional Midwives, a CIMS Organizational Member, stated the study "is far from the high-quality rigorous review that health care providers and the public expect."

Also, commenting on the study, Geradine Simkins, CNM, MSN, president of the Midwives Alliance of North America, a CIMS Organizational Member, stated, "The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman's choice regarding care providers, including skilled midwives, and place of birth."

The study at the heart of this debate, "Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis", originally intended for print publication in the September 2010 issue of the American Journal of Obstetrics and Gynecology (AJOG), was published online on July 1. Researchers and critics suspect that the early release was politically motivated to discredit midwives who attend the majority of home births in the U.S. and to discourage legislators from passing increasingly pro-midwife state legislation such as New York State's Midwifery Modernization Act (Bill S5007a/A8117b), which passed on June 28 with overwhelming bipartisan support, providing autonomous practice for all licensed midwives working in all settings.

CIMS' advisor, Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia believes this is "an unabashed attempt to have poor science cover-unsuccessfully-a political agenda. I am very surprised that the [Journal] would publish it, let alone call it 'Editors Choice'."

According to the CDC, the number of women opting to have their babies at home has been increasing since 1990 and rose by 5% in 2005 and remained steady in 2006. This is significant because it marked the first time in 14 years that the percentage of out-of-hospital births increased in the U.S. In 2006 there were 4.2 million births in the U.S., of which approximately 25,000 (.59%) were home births. About 61% of home births were attended by midwives. Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse-midwives, and nearly three-fourths (73%) were delivered by other professional midwives.

"Women choose to have a home birth for many reasons," states Nicette Jukelevics, chair of the CIMS Coalition Building Committee. "For financial, cultural or religions concerns, lack of transportation in rural areas, or to give birth in a supportive, low-intervention, familiar environment. Other countries like Great Britain, Ireland, Canada, and the Netherlands support women's choice for home birth. The unsubstantiated controversy against planned homebirth with a qualified provider has been with us for many decades. It's time that women in the U.S. have the same right and opportunity to give birth as they choose."

About CIMS: The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. Media Inquiries: Denna Suko (919) 863-9482, dsuko@motherfriendly.org.

Responses to AJOG's "Meta-Analysis" Against Homebirth

In July's American Journal of Obstetrics and Gynecology, a self-proclaimed meta-analysis denounced homebirth, concluding increased neonatal mortality. This conclusion was based on a study that has proven highly misleading, as the following responses from the Midwives Alliance of North America and The Big Push for Midwives Campaign articulate. Born in Sarasota supports both of these organizations and endorses the following statements.

Response from the Midwives Alliance of North America:

A new meta-analysis rushed to on-line publication well before its availability in print, concluded that less medical intervention, which is a characteristic feature of planned home birth, is associated with a tripling of the neonatal mortality rate compared with planned hospital births. In a study published online on July 1, 2010 in the American Journal of Obstetrics and Gynecology (AJOG), researchers at Maine Medical Center in Portland, Maine analyzed the results of multiple studies from around the world. The lead investigator, Joseph R. Wax, MD, Department of Obstetrics and Gynecology, Maine Medical Center, stated, “Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group.”

However, Canadian researchers whose data showing the safety of home birth in a well-organized and regulated system, were used in the meta-analysis, are sharply critical of the study. Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia said the U.S. conclusions did not consider the facts. “A meta-analysis is only as good as the articles entered into the meta-analysis—garbage in, garbage out. Moreover, within the article, Wax et al did their own sub-analysis of the studies in the meta-analysis, after removing out-of-date and low quality studies, and found no difference between home and hospital births for perinatal or neonatal mortality. Yet in the conclusion, they choose to report the results of the flawed total meta-analysis, which showed the increased neonatal mortality rate.” Klein said that this is apparently a “politically motivated study in line with the policy of the American College of Obstetricians and Gynecolgists (ACOG) who is unalterably opposed to homebirth.”

Saraswathi Vedam, a nurse midwife and researcher at the University of British Columbia who is considered to be an expert on assessing the quality of literature related to homebirth, states that the study is deeply flawed for several reasons, particularly, “the authors’ conclusions are not supported by their own statistical analysis.” Vedam states that Dr. Wax et al acknowledges the consistent findings of low perinatal and neonatal mortality in planned home births across the best quality studies they reviewed “but amazingly Wax does not emphasize or even mention this in his sole conclusion.” This begs the question of whether the author’s analysis and reporting of reviewed articles on homebirth do not support his foregone conclusion about the safety of homebirth.

The Midwives Alliance of North America, a professional organization of over 1200 members, believes childbearing women and those involved in maternal and child health policy should be made aware of the flaws and erroneous claims in the Wax et al study. There is a substantial body of evidence-based literature from well-designed studies that establishes the safety of planned homebirth with a skilled birth attendant. The fact that the American College of Obstetricians and Gynecologists maintains its position in opposition to homebirth, despite the evidence of its safety and efficacy, makes one question ACOG’s motive in publishing Wax’s substandard study.

Midwives are the primary care providers in out of hospital settings. Whether their work is studied and scrutinized here in the US or abroad the findings are consistent. Trained midwives are qualified health professionals with the requisite expertise to provide mothers and newborns with outstanding care, using less intervention, resulting in maternal and infant outcomes as good as those in hospital settings under the care of obstetricians.

The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.

Response from The Big Push for Midwives Campaign:

As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.

“Many of the studies from which the author’s conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out.” said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. “The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science.”

Advocates working to expand access to out-of-hospital maternity care questioned the timing of AJOG’s public relations efforts on behalf of a study that won’t be published until next fall. “Given the fact that New York just passed a bill providing autonomous practice for all licensed midwives working in all settings, while Massachusetts is poised to do the same, the timing of this study could not be better for the physician groups that have been fighting so hard to defeat pro-midwife bills there and in other states,” said Susan M. Jenkins, Legal Counsel for The Big Push for Midwives Campaign. “Clearly the intent is to fuel fear-based myths about the safety of professional midwifery care in out-of-hospital settings. Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians.”

The United States recognizes two categories of midwives: Certified Nurse-Midwives, who are trained to practice in hospital settings and who also provide primary and well-woman care, and Certified Professional Midwives, who undergo specialized clinical training to provide maternity care in out-of-hospital settings. Research consistently shows that midwife outcomes in all settings are equivalent to those of physicians, but with far fewer costly and preventable interventions, including a significant reduction in pre-term and low birth weight births, and as much as a five-fold decrease in cesarean surgeries.

The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives includes educating state and national policymakers about the reduced costs and improved outcomes associated with births managed by CPMs in private homes and freestanding birth centers.

Response to Boston Globe Midwifery Debate

An editorial debate in last week's Boston Globe caught my attention. The subject: should midwives be autonomous care providers, licensed and regulated by the state's government (as are physicians), or should they practice subordinately to and under the supervision of physicians?

The the initial editorial in The Boston Globe focused on the rise in cesarean section rates, calling for expansion of midwifery access, including licensure of Certified Professional Midwives, as one of three key measures to reversing the trend (the others being stricter induction protocols and increased access to VBAC--I could not agree more). An excerpt:

Enhancing access to midwifery care might well be the most effective approach to safely reducing the overall caesarean rate — and could lead to significant cost savings and improvement in other priority areas such as breastfeeding. It would also address the impending shortage of obstetric providers. The Legislature should pass a bill to expand access to midwifery care in Massachusetts. We must finally make midwives more central in maternity care — as do all other countries whose birth outcomes are superior to ours.

Its rebuttal argued that the CNM's and CM's currently practicing under physician regulation are serving women adequately, and that CPM's do not have adequate training to be state-regulated:

This bill would license certified professional midwives, formerly called “lay midwives,’’ who don’t even have to have a high school diploma to attain certification. This could also potentially cost the state millions of dollars during difficult economic times. Yes, we all care about the caesareans rate and need to develop strategies to improve access to care by qualified providers in safe settings. However, licensing individuals without adequate training is a dangerous proposal and not the answer to challenges in the health care system.

This argument is predicated on several misconceptions. While CNM's certainly do serve women who seek their care adequately, they most frequently practice in hospitals, where the Midwives Model of Care is desperately needed. CPM's specialize in out-of-hospital births, and although lay midwives also practice(d) outside of hospital walls, Certified Professional Midwives and lay midwives are not, nor were they formerly, the same. To clarify (from the Midwives' Alliance of North America):

Certified Professional Midwife (CPM)

A Certified Professional Midwife is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings.

Lay Midwife

The term "Lay Midwife" has been used to designate an uncertified or unlicensed midwife who was educated through informal routes such as self-study or apprenticeship rather than through a formal program. This term does not necessarily mean a low level of education, just that the midwife either chose not to become certified or licensed, or there was no certification available for her type of education (as was the fact before the Certified Professional Midwife credential was available). Other similar terms to describe uncertified or unlicensed midwives are traditional midwife, traditional birth attendant, granny midwife and independent midwife.

CPMs follow the practice standards of the National Association of Certified Professional Midwives (NACPM), which include the development of collaborative relationships with other healthcare practitioners who can provide care outside the scope of midwifery practice when necessary. The NACPM standards limit the CPM scope of practice to the primary maternity care of healthy women experiencing normal pregnancies.

In Florida, most Licensed Midwives (LM's) also hold the CPM credential, though it is not recognized by the state. The Midwifery Practice Act is upheld by the Council of Licensed Midwifery, a division of the Department of Health. While Florida licensure requirements include and in many cases exceed those of the CPM, the lack of CPM recognition does pose problems in situations like reciprocal practice (when a midwife is licensed elsewhere and wishes to practice in Florida) and Medicaid reimbursement.

Another point argued on both sides of the Boston Globe debate was the cost to taxpayers vs. cost savings of midwifery licensure. While creating a body of regulation in a state, such as Massachusetts, may initially cost taxpayers, the cost savings generated by licensed midwives is astronomical, and has been projected by many to have the potential to save states millions and our nation billions in healthcare costs. In Washington, the Department of Health mandated a study to investigate this very question, and the answer was resounding. Midwives saved taxpayers there $2.7 million annually, reducing intervention and surgery rates without compromising outcomes. Should a similar study be conducted here, it would reveal (by my own number-crunching) that Florida's midwives save almost four times that amount, with our higher population, percentage of births paid for by Medicaid, and current cesarean rates that are second in the nation.

Increased access to midwifery care, including licensure of Certified Professional Midwives that specialize in low-risk, normal pregnancies and out-of-hospital births, is a win-win-win situation. Taxpayers win, through significant healthcare cost savings. Mothers, babies and families win, through safe outcomes and a motherbaby-centered, non-interventive, evidence-based model of care. And, believe it or not, physicians win. Partnering with out-of-hospital midwives in a true collaborative model ensures that women are paired with the care provider that best suits their risk level and preference, increasing transparency and informed consent, thereby reducing litigation against physicians that stems from lack of information or discontinuity of care.

BIRTH STORY: Max's Home Birth

(written by Michelle Harmon, about the birth of Maximilian, 11.09.04)

Saturday morning, the 6th of November, 2004, I got up around 11am, went to the bathroom, and noticed a jelly like, clear goop after wiping. It was my mucus plug! The little barrier covering my cervix fell out. Woo hoo! I called my midwife and birth team.

Hal was like, “Oh my god, should I go to work today?!”

This is when I consider the beginning of my labor to be. It’s when my body REALLY started getting ready to push Max out. We carried on as per usual.Hal went to work, after cleaning I took it easy for the rest of the day. I knew it could be a while before labor picked up – I mean, I’m talking a week or so. It was already six days past Max’s due date so we were doing what we could to facilitate the start of my contractions – sex, acupuncture, herbal teas. We weren’t worried. We knew it would happen when my body was ready for it to happen.

Sunday afternoon my long time close friend, Monica, stopped by to clean my car out (I told you we were serious about the cleaning). She drove into town from Gainesville for Max’s birth and was thrilled to be a part of the birth team.I was lucky to have her! Her excitement enhanced mine and her love was much needed. I think the reason it worked having so many people at Max’s birth was because I spent a lot of time talking with them about it. They knew what I needed from them and they all believed in themselves to give – and I believed in them. Labor is not a time when you can be concerned with stepping on another’s feelings. I shared every anxiety I had and we all one on one worked out our expectations. I had the best birth team any laboring mom could hope to have.

Sunday night rolled around and Hal and I went out to eat at the Olive Garden for the last time as a family of two. His brother met us up there and we ate, talked, laughed, and carried on all the while I was having mild contractions that almost stopped me from talking. But, it was my time to be alone with them, to have them without telling anyone.

It was as if my body was whispering, “get ready, their (the contractions) coming and there’s no turning back.”

The food tasted so rich. Everything I looked at was vibrant and strong. Colors on buildings and lights on signs magnified with deep intensity. My senses were heightened and getting ready to check out for the upcoming experience.We got home and the contractions teetered out.

I left a message on my midwife’s answering machine letting her know about the contractions, it was around 9pm, Sunday night. At this point, it wasn’t necessary for her to call me back or rush over. Hal and I talked and fell asleep. This was our last night alone together.

Monday morning we were trying to figure out if Hal should call off from work. His job was letting him take a week off vacation time starting when I went into labor. We went back and forth struggling to decide if we were starting labor today or tomorrow. Finally, he called into work and told them today was the day he needed to start his vacation (which, by the way, the time he took off was not really a vacation). Even if we didn’t start labor today, I thought, there was plenty to do around the house to get ready for it and besides, I wanted his company.

I had a little bloody show early in the afternoon but the day went on contraction free. I ate a lot, slept a lot, and just tried to relax when I was awake. Hal cleaned obsessively all day.

Even when I said to him, “Slow down and take a nap, we might be up all night.”

He would respond, “No, I can’t, must vacuum this dirty carpet!” It was funny to me even at the time but I was a little worried about how he would fair during labor at 3am with no rest during the previous day.

We had a 5pm prenatal visit at the birthing home with our midwife and she suggested coming in if we felt we could (it’s really important not to obsess over early labor – that is a good way to wear yourself out. So, Heidi really stressed carrying on as per usual). On our drive to the birthing home, I started having contractions. These contractions where pretty intense. It became necessary for me to arch my back and squeeze Hal’s hand during each one.

Ohhhh, this is it, I thought. So this is what it’s like to be in labor – one big menstrual cramp!

I had no idea it was going to get worse, nor did I think it was possible.

We’re in the parking lot when Heidi gets out of her car, walks over to us, and is cheerfully like, “So how ya feeling?” Face tense, I responded, “having strong contractions.”

While saying this, I was having one and started to bend over holding onto the nearby car.

“Ohhhh yeah, assuming strange positions. You’re starting to cook!” Heidi exclaimed with enthusiasm. Hal and I chuckled and I was reassured that all was normal.

I was one centimeter dilated at the appointment and was instructed to call Heidi when I was in active labor.

Now, I thought, “Active labor? Wasn’t I in active labor?” Felt pretty intense to me.

I was assured that I would know when active labor hit - that there was no mistaking it – it was so different and so much more intense than early labor. I got a little nervous at this point.

Well, Hal and I, being the food centric folk that we are, decided that we should pick up a few more items at the grocery store to carry us through the next two weeks, at the least. We pulled into the nice grocery store that has the reserved for pregnant mom parking space - which we used for the last time.

One of the clerks walked by me and said with an uneasy look on her face, “giiiirl, I know you not in labor.” Half smiling at the absurdity of my – yes, I am – answer and half just wanting to be left alone, I kept walking.

Every contraction brought me to my elbows hunching over the cart for support. It wasn’t a dramatic scene, not a scene at all, but it was surreal to us. Poor Hal, he was becoming visibly concerned and nervous and just started chucking all the stuff he knew we liked in the cart without thought. The bill was around two hundred dollars – way more than the 50 bucks we planned on spending. The drive home was intense but the contractions were feeling the same.

When we got home, Hal put the groceries away while I took a shower and put my hair in barrettes to keep it out of my face. The whole time I was showering, I knew this was it. I knew this would be my last shower with my pregnant belly.

Hal needed to take the dogs to his parents house and I kinda went back and forth with, Could I stay by myself comfortably or did I need to call Liz to come over before H.G. leaves?

My extremely independent way of managing pain got in the way of reason and I called Liz to just give her the “heads up,” that I was in labor and may be calling back in an hour or so when active labor kicked in.

Hal started to get the dog’s food and before he left I stopped him, called Liz back in tears and cried, “Can you come over now? I don’t want to be alone.”

As soon as she got there Hal gave her the quick low-down on what was happening and bolted out the door with the dogs. She came into the room were I was laboring on the bed and I asked her to spoon me. I needed to feel flesh and warmth to feel safe. She crawled into bed and wrapped herself around my body, we talked a little (I don’t remember what was said), and we went through each contraction together. The fear was really beginning to build.

I needed to get up and move a bit so went out into the living room where I could hear Cerberus Shoal playing on the stereo. Liz and I held each other rocking back and forth, dancing to the soft music while I moaned through a couple more contractions.

I looked at her and said, “I’m so scared.”

“Me too.” She replied.

We cried into each other’s shoulder rocking side to side.

We went back into the bedroom and I screamed my way through a couple more contractions. This, anyone knowledgeable about natural childbirth will tell you, is not the best way to manage the pain. The intensity and pain was picking up. Liz called my midwife and at this point, I was still able to talk so I let Heidi know that I was in some serious pain. As soon as we got off the phone with her, my water broke. Liz called her back to let her know that the liquid was clear and Heidi was like, "I’m on my way – I’ll be there in 45mins."

"Good god!" I thought, I’m going to have this baby in 45 minutes (little did I know, I was just transitioning into active labor which means I had about 6-12 more hours to go)! Hal got back and as soon as he walked into the room I said to him, “I need the trash can, I’ve gotta throw up.” And then it began. Active labor.

I labored with Hal until Heidi got there. Once Heidi arrived and accessed the situation, I felt almost immediate relief and safety. She really calmed me down and helped me to find my center. Before she arrived I was scared and didn’t know if everything was okay. Even though I had intellectual knowledge that my body could birth my baby, I was still extremely dependent on a professional to tell me that I could do it – that everything was going normally. After all, I had never experienced birth before this in any capacity.All I knew was what I had been reading for the last nine months. Although not all of the info went out the window when active labor began, I still needed to be reminded of what I already knew.

As soon as Heidi walked in and began speaking to me, her calmness and certainty made me feel like, “yeah, okay, I can do this.”

I tested positive for Group B Strep, so needed an IV of antibiotics. Heidi was having a hard time finding a vein to cooperate and I was having a hard time sitting still, so we opted for the two shots – one in each hip.

She told me at this time, “If your blood pressure goes one point above normal we are transferring to the hospital.” My blood pressure had been riding a little on the high side throughout my pregnancy but never reached that dangerous point my OB was talking about: preeclamsia high. I was okay with transferring at any point for a medical reason. My decision to have a home birth was based solely on the fact that I wanted an honest opportunity to have a natural child birth. Meaning, no interventions unless medically necessary. I was comforted by Heidi’s stern words.

My friend, and one of four birth team members, Phil, arrived and was directed by Heidi to get the pool out of her car so Liz and him could start setting it up. Hal was by my side the entire time. The only two people I was tuned into were Heidi and Hal. I would even say that Heidi was my spiritual link to our world and Hal was my physical link and support. My eyes were pretty much closed from here on out only opening when I needed to see where I was stepping. I tried lying on the bed and relaxing while the pool was being filled with air and then water. I threw up again. Two garbage cans were required as part of my home birth supply list and a roll of garbage bags. While I was preparing for this, I remember thinking, what will this be used for? Or, why two?

Finally, the pool was filled and ready for me. I was a little leery about getting totally nude in front of Phil so slid into the pool with my undies and sports bra. When in the pool, I didn’t like the way the cotton felt on my skin, so took off my underwear.

Shortly after I got into the pool, the phone rang. I could hear Hal’s mom’s voice yelling for him to pick up the phone. She called like three times in a row – I wanted to rip the phone out of the wall.

Things started to really pick up after this, my contractions were closer together (we never timed them, not once), they were painful enough to cut off my use of words, and my memory at this point is encumbered by the power of the primitive spirit.

I fell into a place that didn’t allow for language to seep in. Any time I tried to think of something specific my mind just simply did not allow words to form, and I had to stop thinking. I just became what I was doing. I’ve never felt so one with spirit and body in my life as I did when I was in active labor. I could have been laboring a million and one years ago and it wouldn’t have felt any different. The connection to my primitive spirit was strong, beautiful, powerful, wild, and uninhibited. As labor progressed, I began to move on instinct alone.

I labored hard but more comfortably while in the water. I moaned, moved, and cried. I did this until I found my home within. I say, “Home within,” because at some point while in the water, I became pain. I was no longer afraid of it. I actually welcomed instead of dreaded each contraction. Before this point, I had moments of doubt, moments when I said out loud, I don’t think I can do this. Fortunately, Heidi knew I could and as Hal put it, she didn’t even entertain the thought of transferring to the hospital. It was her belief in me, her support alone that helped me find the way to that sacred place within that only I could travel. My friends and Hal were a big part of the support I needed, but it was Heidi that had the power to "make or break" my confidence.

I reached 10cm while in the pool – mind you, Heidi didn’t check me every hour. She ASKED if I wanted to be checked and I said yes. She told me to listen to my body and let it lead me into pushing. Some people say pushing is the best part for them. Well, for me, it was the hardest part. Before I started to push, I got to a point where I thought I could labor for hours. I even fell asleep between contractions (30seconds to a minute little sleepy-time). All I had to do was whisper, water or juice, and a straw was brought to my mouth. My other two friends arrived, I don’t know when, and just slipped right into the groove of serving the laboring women while being quieter than a mouse.

When I started to push, the part of labor Heidi kept referring to as “athletic” during our prenatal visits, became clear to me. I was pushing in the pool for a while when Heidi suggested sitting on the toilet to let gravity help bring Max down through the birth canal. Otherwise, she said, I could be laboring in the pool until the following day. I was nude except my black sports bra and didn’t even give getting out of the pool in front of all my friends a second thought.Modesty no-more.

While on the toilet I pushed and pushed and pooped and pooped. I actually got a little embarrassed and tried to clean my ass right there in the middle of laboring! Heidi said in a calm motherly voice, everybody poops, Michelle. I chuckled at her and thought of the children’s book. Okay, I had to surrender to the reality of pooping in front of people. I surrendered immediately.

After pushing on the toilet, I moved to the vanity area to get into a squatting position. As I was moving from one location to the other, a contraction came on bringing me to hands and knees. Moaning and pushing, it passed. After it passed, I got into position to squat and push through the next one. Heidi sat in front of me, the large pad underneath my body to catch liquid, blood, poop, baby - what-ever decided to come out. Hal on one side, Heidi’s birth assistant on the other.

I barely made it through the contraction before I started to say, "Hal can’t do this, his back!"

Hal has a herniated disk that he wasn’t thinking about, but I was. Shoot, I needed him to be strong after Max was born, too! For the next few contractions, Liz stepped in to support my 250lb. body into a squatting position. The two women holding me weighed half of what I did! But, their strength and desire to help combined was enough to support this big mamma’s weight.

We moved to the bed, next. This is where I started to feel sheer exhaustion kick in. To feel like I was making progress, Heidi asked me if I wanted her to keep her fingers inside of me during each contraction. YES! I said. I needed to feel like I was making steps forward because it was such hard work. I also didn’t want to feel like I was alone. I labored in this position the longest: on my back propped up by Hal who was sitting behind me. Liz was pushing my right leg back through each contraction; the birth assistant had the other leg.Heidi was in front of me, Monica behind her and Phil and Jenna alternated holding my right hand and giving me drinks. We were all getting tired and we all felt like Max would never come (except Heidi, of-course). My moaning turned into growling a deep throaty growl.

This is the moment where I felt the most connected to Heidi. At one point during my pushing when she needed to leave me to use the bathroom, I felt connected to her in a weird I can see you even with my eyes closedkinda way.

She made a little joke, “If you have a contraction, you know what to do!” Everyone kinda giggled languidly and she walked away.

"Okay," I thought, "I’ll just wait for you to get back before I have another one."

I listened to her pee, the toilet flushed, she washed her hands, went into the living room, started walking back towards the bedroom, in the hall way – okay contraction, you can come now. She was back in time to put her fingers inside of me to guide Max down. That was the longest pause between contractions that I had since starting to push.

Then, Heidi said, “Look, Monica, can you see that, that is Max’s head! Your baby is coming soon, Michelle. Push for your baby.” I got excited knowing that the head was finally visible.

I heard Monica in a child-like excited voice, “oh my gosh, I see it! I see the head!” I was like, YES! Finally!

Again, Heidi suggested changing positions. Man, was this getting annoying. When the heck was I going to get to see my baby?! I tried going through a contraction while lying over the birth ball, nope, didn’t work. I threw the ball accidentally hitting Phil with it while saying, “I don’t like this!”

I heard him respond, “Umph, okay,” before my next contraction came.

And then, all of a sudden, I was like, I need to get back in the water. I need to get back in the pool right now.

I was helped back into the pool. As I began to sit down in it, a contraction came on so I fell down in a squatting position.

“Yes!” Heidi yelled. “That’s it, Michelle! Do that again!”

Now, when I say "yelled," let me tell you, she didn’t yell like in a high pitch loud voice. It was more a tone of excitement than loudness. It was a tone that really motivated me to keep going - to keep pushing. A few more pushes, one right after another, I was holding on to the tub and to my friend Monica and I heard Heidi asking her birth assistant to watch the time. I looked at Monica, remembering she has scoliosis and not wanting to hurt her, and asked if she was alright. She said yes and before she got to the “s” part of yes, I was pushing again.

“Okay, now Michelle - little pushes. Cough him out, now. He’s crowning.”

*cough, cough* I pulled my black bra off wanting, anticipating, his skin on my breast.

“Do you want to feel his head?”

“No, I’m scared.” I cried.

Hal and Monica, with my permission, touched his head while he was crowning.

“Okay, his head is out. Now gentle but good push and he’ll be out. Hal, hold your hands like this to catch him.” Push.

I felt his whole body slide out of me. I fell back with relief and desire to hold him. I saw Hal’s face while he held him and looked at him – big smile and teary eyed. He put him on my chest immediately.

I lay there with baby on chest waiting for that sweet first cry. Exhausted. Blissful. Proud. There was commotion around me but all I cared about was Max and Hal.

Heidi gently rubbed his feet and he let out a cry. The most beautiful cry he will ever let out.

Heidi didn't forget about the placenta, like I did, and said, “With your next contraction, you’ll birth the placenta.” A few moments passed, I contracted lightly and she said, “Give a push - it will be easy and painless because there are no bones in this.” I birthed the placenta. It was perfect and healthy.

Hal and I crawled into our bed with Max and gazed at him. Hal held him while I was being checked. I didn’t tear at all but had a mean looking hemorrhoid. After being checked and having my tummy massaged to help the uterus detract, I took a shower.

Jenna made me some food, which I hardly ate, Heidi took care of the medical stuff with Max, and Hal passed out on the bed for about an hour. Max took a bowel movement on his way out so Heidi had to put a tube down his nose and suck out the meconium that was in his lungs. He was breathing kinda funny but eventually started breathing normal after Heidi cleared his lungs. There wasn’t a lot of meconium so she wasn’t worried. After all was “Okayed” with Max, I tried to nurse him. It wasn’t easy but we (me with Heidi’s help) got him to successfully latch on. Everyone left. Hal fell into a deep sleep and I snoozed with Max on my chest. It was 6am. We took him to the pediatrician’s for a 2pm appointment that Tuesday afternoon and got the second, “he’s perfectly healthy,” stamp of approval and started our new life. In a daze, but we made it.