Midwifery Education

Barb's blog has a new post entitled Midwifery Education , a spin-off from a conversation that has been happening over at another blog (which I have to admit I haven't had time to read at all).

I have so much to say to this post, including the desire to read the referenced blog to discover where the origins and thought processes are of these two midwives.

Access to midwifery education and the homogenizing of midwives is something I feel very passionate about for many reasons, most rooted in feminism, entitlement and classism. Unfortunately, I'm in the midst of laboring women, getting over a cold, being up all night and getting ready for the Trust Birth Conference. Suffice to say I think it may take me a couple days to organize my feelings, my thoughts and my words.

Spoke at a statewide mini-conference yesterday about Autonomous 2nd and 3rd stage. It was a nice training for the Trust Birth Conference, even though I was suffering from a cold with DayQuil on board. Overall the response was positive and it reinforced issues I want to cover at the conference in California.

I leave for the conference on Thursday afternoon with my dear friend, Linda. I'm thrilled she will be joining me at the conference - and sharing a room with me, a client of mine and a wonderful doula from Seattle.

I'm so excited to be in an environment of people who are truly passionate about changing the world by speaking birth truth. It is a bit like that fantasy slumber party scenario I wrote about years ago...only I'm missing Sara Wickham and Cornelia Enning. Rixa should also be on that list, but I wasn't aware of her gifts at the time I wrote the entry. With some chocolate and a glass of red wine perhaps I can gather them all in my room for a brainstorming session. You can bet I'll be taking ALOT of pictures and blogging along the way!

Was up late last night with friends, celebrating the receipt of a grant which one of our good friends will use to produce an exhibit about an artist friend of ours (does that make sense?). Had a wonderful dinner of Macademia nut-encrusted MahiMahi with mango sauce...came home at 2am and was called to a labor at 4.30am. We came home almost twelve hours later since the labor was easing in and out - and surely our watchful eyes were not helping anything.

Slept for a bit, went to dinner with my girlfriend and then to Target. Now I'm here, knowing that I need some serious down time instead of getting all those swirling thoughts put out on this blog. Once I feel articulate and concise I will be back to share some of my feelings.

There is a mom that was due around Valentine's Day that hasn't birthed, two VBAC moms waiting in the wings (one of which is doing labor work), a first time mom and two other moms planning their second babies, second homebirths, all due within the first two weeks of March. While it's not within my control, I selfishly want these women to either birth before I leave or wait until I return. I realize that either way March is going to be a busy month, followed by a full schedule all the way through August. We knew that I had this time scheduled for the conference when they hired me, I'm always knocked over by the level of attachment I feel towards my clients and how very difficult it is to leave them - even if they are in wise, caring hands.

Off to snuggle with my girlfriend and watch some junk TV.

Happy March!

Oregon's voluntary licensure

In response to my post about the prospective study that Missy Cheney from the Oregon State University is creating, my friend Linda wrote this:

(note: Kraig Bohot is the Communications Director for the Oregon Health Licensing Office, the office that oversees the Licensed Direct-Entry Midwifery Board)

Linda said...

Melissa seems to be very happy to answer questions about the study. Her email is cheyneym at onid.orst.edu.

I've corresponded with Kraig Bohot. His stance is basically that the regulatory board is made up of people who support the midwifery model of birth (whatever that means, I'm not so sure anymore) and that therefore they can be trusted as an authority. Their function, then, is beneficial to all, so that it makes no sense not to protect consumers by holding midwives to the board's standards. (The context of part of my response below was that he had explained in detail to me how the regulatory standards are devised, and that the OHLA realizes that this is an emotional issue.) I wrote to him,

"I know how the regulatory standards for licensed midwifery practice are decided on in the state of Oregon and I appreciate that it's a much better situation for midwives and homebirthers than in most states. The fact remains, however, that the people responsible for establishing those standards are fallible and biased toward what they personally value and believe to be true. There are others who do not share their values and beliefs, and therefore do not accept them as an authority in determining what is and isn't appropriate in birth. This is why it is wrong to make midwifery licensure mandatory.

If Oregon decides to mandate regulation of all forms of midwifery it will have crossed the line from protector to police state. That might not be a problem
if we could assume that the standards are and will remain appropriate for all people. But it's a slippery slope. The regulatory board will change over time and it's quite possible that it will become more restrictive. I'm sure you're aware that in Washington and California, despite these being relatively progressive states, standards for licensure and laws regarding birth practices in general are far more restrictive than they are here. And in most other states, they are even more so (even to the extent of homebirth midwifery being illegal.)

Oregon is in a leadership position in this respect, representative of the fact that birth cannot be objectively defined in only one way, with one set of beliefs governing how an autonomic bodily process should be handled. Oregon has so far refused to define birth as inherently a medical event necessitating management by a medical professional. Mandating licensure would negate that.

Women already have the option of selecting a state-sanctioned care provider, if they agree with the beliefs of those people the state has appointed to determine how licensed care providers must operate. We also have the option to select a support person outside of that closed system, in accordance with other beliefs. In a moral society, that option would remain available.

Yes, this is emotional, and that's because it matters. Many have been harmed by the obstetric model of care, which unfortunately informs much of modern midwifery. This model is not wholly evidence-based and is not the objective pinnacle of birth wisdom. It makes no sense, then, to give it the ultimate right to dictate that all births and types of midwifery must fall under its rule. The state should not be able to tell anyone that they cannot step outside of that model and self-tailor their care in the interest of a better outcome. If the state decides to regulate midwifery, it will be doing so ostensibly to protect me and others like me from ourselves. This is arrogant and demeaning. It assumes
that the midwifery regulatory board knows better than any individual what is best for them.

I am sure that those who are pushing for mandatory licensure are well-meaning. And I agree that it is important to advocate for consumers. But this is simply not a case in which we can say without question that one set of standards is right and all others are wrong, and to not only insist that this is so, but to *force* others to abide by it is *not* in the best interest of consumers. Allowing all of us to make our own informed choices, even if they are different from the norm, is."

As an addendum to what Linda has written: The Oregon Licensed Direct-Entry Midwifery Board is made up of a homebirth-friendly MD, two CNMs and three Licensed Direct-Entry Midwives. It is NOT overseen by a board of physicians without knowledge, education and experience of homebirth. It is, in my experience, the most peer-friendly board that oversees non-nurse midwives in existence.

midwifery - practice of medicine?

I am limited in my online time and it feels like anything I write or respond to never quite conveys my initial intention. Two year old distractions, a 13 year old wanting to look at the latest YouTube craze - it all takes me away from getting my thoughts down succinctly. Bear with me.

Here are a couple looks at the concept of midwifery as the practice of medicine - and why some view it as not the same.

(What is interesting to me is that the most vocal opponents of homebirth midwifery are not doctors - they are the nurses unions/associations. I find this interesting mainly because I view RNs as the single make/break of a positive birth experience in the hospital. RNs, to me, are in a tough spot because they see the action of someone else causing reactions that they are witness to. I know that many RNs in L&D are HUGE patient advocates, to the point where they will hold off calling docs or stretching the truth a bit in conveying progress in order to help a woman maintain control over her birth experience. Having had numerous experiences with RNs - including attending homebirths for them - I know the truth about what frustrations many deal with on a day-to-day basis. I think that much of this coincides with the negative feelings about homebirth midwifery. I'd like to hear more from RNs on this, for sure!)

Midwifery is Not the Practice of Medicine

North American Registry of Midwives' Position Paper on the Practice of Midwifery

I really, honestly appreciate the willingness of people to push me, to challenge my thoughts. This is the sort of thing that moves the truth forward and clarifies intention. It also brings us together with similar goals in mind - and for that, I'm grateful.

Oregon midwifey news

Here is a story published in the Portland newspaper, The Oregonian about midwives and gathering midwifery statistics.

In 1977, Oregon's attorney general held that midwives didn't require licenses to attend births without drugs or surgical procedures, says Maryl Smith, a historian with the midwifery council. Five years later, the midwifery council began a voluntary certification program that included an exam and experience requirements. By 1993, the Legislature established voluntary licensing, intending it to allow for reimbursement under medical assistance programs.

Licensing is a hot-button issue among midwives, Cheyney says. For starters, a license costs $1,500 a year, a fee some midwives struggle to pay. But most who avoid licensure do so because of their philosophical beliefs.

"They don't want to be part of this government body," Cheyney says. "They don't want somebody interfering with the art of midwifery. Then it's not mother-driven."

Viles says the move to licensure created rifts that took time to heal.

"I chose to be unlicensed because I felt it was the best way to uphold and affirm my belief and the Legislature's intent that birth is a natural body process and not a medical event," she says.

My stance on state licensure of midwives is that it should have a voluntary option, not mandatory. To mandate that all midwives be licensed only will further serve to alienate midwives, put them at risk for criminalization due to not licensing (for various reasons listed above), and severely restrict true freedom of choice for families.

I believe that every state interested in making midwives legal start with voluntary licensure, using Oregon as an example. There is no reason why any midwife should risk criminalization simply for attending families in birth.

Stem cells in breastmilk

From Science Alert in Australia and New Zealand: Breast milk contains stem cells

[Breastmilk] not only meets all the nutritional needs of a growing infant but contains key markers that guide his or her development into adulthood.

“We already know how breast milk provides for the baby’s nutritional needs, but we are only just beginning to understand that it probably performs many other functions,” says Dr Cregan, a molecular biologist at The University of Western Australia.

He says that, in essence, a new mother’s mammary glands take over from the placenta to provide the development guidance to ensure a baby’s genetic destiny is fulfilled.

“It is setting the baby up for the perfect development,” he says. “We already know that babies who are breast fed have an IQ advantage and that there’s a raft of other health benefits. Researchers also believe that the protective effects of being breast fed continue well into adult life.

“The point is that many mothers see milks as identical – formula milk and breast milk look the same so they must be the same. But we know now that they are quite different and a lot of the effects of breast milk versus formula don’t become apparent for decades. Formula companies have focussed on matching breast milk’s nutritional qualities but formula can never provide the developmental guidance.”

His team cultured cells from human breast milk and found a population that tested positive for the stem cell marker, nestin. Further analysis showed that a side population of the stem cells were of multiple lineages with the potential to differentiate into multiple cell types. This means the cells could potentially be “reprogrammed” to form many types of human tissue.

From Gloria Lemay

There has been a lot of discussion on midwifery and childbirth email lists in the past few weeks in reaction to a statement by ACOG that birth should take place in hospital. I can’t understand, for the life of me, why ACOG’s opinion on homebirth would interest anyone remotely associated with childbirth.

Aren’t these the illustrious folks who gave us 50 years of universal episiotomies? Aren’t they the people who prescribed thalidomide, high dose birth control pills, and hormone replacement for vast numbers of menopausal women? Aren’t they the ones who have made a fortune from amputating the foreskins of millions of helpless baby boys? Haven’t they unnecessarily induced labour and cut the bellies of millions of trusting women? Need I go on? Really, why would any right thinking woman be dissuaded from homebirth by the opinion of ACOG?

Although I didn’t even bother to read their statement on homebirth because I could care less, I DID want to see what they had to say last week about collecting cord blood for freezing. Now, THAT was interesting. They did not go the way of the British Society which clearly tells their members that freezing cord blood is a scam that should be done away with by intelligent people. http://thecordblood.net/?p=25 No, the American group (some call them the S. O. B.’s) tells their members that they should be informing their patients about the back door payments they receive for soliciting for the cord blood monsters. If you look closely at their statement, the message is there that cord blood banking is a ridiculous waste of money for no earthly good whatsoever but the door is left wide open for the obstetricians to continue padding their bank accounts from the stupidity of the public.

http://www.acog.org/from_home/publications/press_releases/nr02-01-08-2.cfm

ACOG has lost credibility with the women of N. America. When midwives, nurses and doulas realize that fact, they will stop caring what ACOG has to say. It would be of more interest to me what the Teamster’s Union thinks about homebirth.

Gloria Lemay, Vancouver, BC

www.consciouswoman.org

Homebirth in Britain, a series of videos

Let's not forget what the Royal College of Midwives and the Royal College of Obstetrician and Gynecologists have to say about homebirth. A complete opposite of what our American counterparts believe: that a woman has the right (and intelligence to make the choice) to birth her baby not only gently, but safely.

Would socialized medicine change our attitudes about birth simply because of the cost-effectiveness? (Many countries with socialized medicine have done away with routine procedures and interventions that are not evidence-based to help reduce overall expenditures.) What if we instilled a no-fault malpractice system?

Trust Birth Conference

One of my clients decided recently to attend the Trust Birth Conference in March. From her perspective, there was a struggle with going. Was this conference just for those involved in birth work - childbirth educators, doulas, midwives, doctors, nurses? Or could she, a mother pregnant with her third, gain something from attending?

Never have I been presented with a conference that offers so much value to our entire culture. To say that it's a conference for those involved in birthwork is limiting the focus. This conference is different in that the goal is to shift the awareness and thinking about how we all approach birth. It's not a black/white look at birth - instead, it is an opportunity to reflect and check in with our own biases, fears and approach to birth.

Some carry a misconception about this conference. That somehow it is about people who are blindly naive about risks in birth. That when we say we TRUST BIRTH, somehow it just defines thinking that every woman can give birth without any complications. Nothing could be farther from the truth.

This, to me, is what it means to TRUST BIRTH:

As a woman and a mother I am born with a deep level of intuition. Sometimes fear arises in this place of intuition - and it is not my job to figure out what is just fear or what is a strong intuition. As a woman and mother, they are both the same. They both direct me and guide me. When another person invalidates my fear/intuition, I begin to doubt myself and my intuition. When I am challenged about my beliefs, I grow. I learn more and this will likely shift my awareness about how I process my intuition. In essence, my sense of intuition becomes a larger, stronger part of my life.

As a midwife, I have my own sense of intuition. I also have my own set of fears. At birth, I struggle with what I know to be true about how we are made and also what my experience has been. The role of anecdotal experience does not make things true for all women in my practice. I'm shown this repeatedly by the universe/God. Just because I've experienced something that was relatively scary a couple times doesn't mean I should expect it at every birth - or that I should routinely intervene at every labor/birth to ease my concerns that it doesn't happen again. It does mean that when signs show up, I am on alert and processing the things that are THEN occurring. When there is a matter of necessitating assistance, or even communicating with the parents what I feel, I move to do so. Routine intervention always has a trade off - usually a negative one.

Trusting Birth in the truest sense means knowing that birth does work beautifully. What we're up against isn't defects in the birth process (though there are variations that require assistance, interventions and different outcomes than what we originally expected), but a cultural brainwashing about the process of birth. It's about challenging yourself to look at what we're taught, what we believe and what we know to be true medically, physiologically and emotionally.

TRUSTING BIRTH. We're not there yet. I'm not there yet. I am not sure that I ever will be in the way that I expect from myself - I am living in this culture, bombarded by the same doubts, the same selfish desires and struggles as anyone else. It's taken me years to get to this place where I am right now - and while it's a far cry from where I stood ten years ago, I'm still aware of how much more I have to travel.

The process of being involved with birth has changed one major thing in my life: my perception of who I am. My ability to be humble to the fact that many times birth has nothing to do with me as a midwife. I can offer assistance, support and love for my clients but their journey is their own. I sincerely hope that I'm self-reflective enough to withstand disappointment that someone may have with my role, and smart enough to use that to move forward and make adjustments in my views/communication.

In essence, birthwork has empowered me. When I started this path I was focused on empowering women. There was no focus on what this path had in mind for ME. It was about caring for women, assisting them, doing for them. Every cesarean or transport was a failure on my part. I was still in this place of feeling like birth outcomes were about ME.

Letting go of those expectations, realizing that I'm a partner in a woman's care and actually being witness to unhindered, gentle birth has empowered me as a PERSON. It has given me hope for humankind, hope for children and a sense of faith that I never would have learned otherwise.

I am going to the Trust Birth Conference not because I have been asked to speak. I am going because there is still so much I have to learn - when I'm uncomfortable, facing those issues head on will only help me grow even if my views don't necessarily change. It's about being around people who are on the same path, seeking the same personal truth, the same challenges.

Trusting Birth is about working on deprogramming ourselves. Whether you're a midwife, mother or doctor, we all have elements of birth fear that has been deeply ingrained on a cellular level. Sadly, it is generations old. Talk to our grandmothers, our great-grandmothers - these are beliefs that are still being taught to our children. When we talk about BIRTH TRUST we begin to shift those cells - and in essence, shift the dominant paradigm.

I trust that birth works. I trust that labors and births that are not routinely directed, managed or interfered with work the best. I know that babies have incredible adaptability (a thought brought up by my apprentice/assistant) when not faced with drugs or routine intervention. I trust that mothers and attendants have a same mutual goal: a healthy baby and a healthy mom.

I also trust that our ideas and thoughts are leading us to a place where, when really needed, we have technology and specialized assistance available. I trust that women are the experts in their care and have more at stake than their providers to see a healthy outcome of themselves and their baby. I trust that we have gotten to this level of humankind because of a perfect, awe-inspiring design.

I am not naive by trusting birth. I am merely open to the idea that birth was created, as Karen Strange repeatedly says in her Neonatal Resuscitation classes, "to work even if a woman is alone." I trust birth because trillions do it. Every second of every day. Despite the odds that women and babies constantly face, the vast majority survive, whether it's birthing solo or birthing by cesarean. Our bodies - and our babies - are built for survival.

I trust birth because I trust God. I believe that every human being has the fundamental right to a healthy, gentle start in life. I believe that birth is more than the emergence of a healthy fetus from a healthy woman's womb. I believe that birth is a life-changing event that affects how we view ourselves as women and how children are treated in our world.

We are up against a culture that distrusts birth. That distrusts women. That expects catastrophe. That looks at legal ramifications rather than personalized care. That puts providers on a pedestal.

If you're a parent and are interested in being challenged, sharing your truth and offering your story, please join us at the Trust Birth Conference. The organizers have created a path in the conference that is geared towards parents at a lower cost. Though I must tell you that the whole conference will change your life.

Trusting Birth is not about being blind. It's about having your eyes wide open, moving forward, hearing what is being said, processing it and making your own decisions. If we're afraid to do those things, how can we ever trust ourselves as parents?

A response to the fellows

Rixa has an amazing, honest and accurate response to the recent ACOG press release on homebirth.

She says it much more succinctly than I ever could.

While I wouldn't expect them to say anything differently, the patronizing tone of the release (that somehow a mother just wants a candlelit romantic experience and cares little for her health or that of her baby's) really disappointed me.

We are part of a large, successful, truth-seeking movement...proved specifically by the defensiveness of this release.

The Pressure on Doctors

It's easy to get down on all physicians providing obstetrical care in a hospital setting. Knowing doctors personally and professionally I realize there are many out there that are struggling against the hostile rise in cesarean sections and practice approaches. The book Pushed offers an honest look at the pressure and conflict that many obstetricians face.

In my state there are not many choices for malpractice insurance. In fact, as of this writing, there are two companies that offer such coverage. Both insurance companies offer a premium discount for practices with higher cesarean rates. Why? In court a cesarean is always going to be viewed as the safest route of delivery (for the infant, which is where most malpractice claims arise). Hence, if you do more cesarean births the insurance company is less likely to pay out millions of dollars in litigation. This pressure has led many providers to stop doing births in my community. In essence, the docs that honor evidence-based approaches to care are getting tired of the fight and leaving birthwork altogether.

Here is a recent article published about a doctor that is in the same predicament in North Carolina...one that forced her to leave a booming obstetrical practice altogether. Her stance and the truth she speaks about is important - not only for consumers but also for other providers. If a stance is taken against this sort of climate could we see change occur?

From the article:

"I don't see any end in sight right now," said Dr. Bruce Flamm, regional chairman of The American College of Obstetricians and Gynecologists, saying there's little concrete data on how many c-sections are unnecessary. "All of the current pressures seem to be going in the direction of more c-sections, not less."

He and other national medical experts are concerned with the trend; a trend they believe is pushed by medical liability issues, convenience for both doctors and patients, and perhaps hospitals' financial and staffing pressures.

"There are some doctors who say the only cesarean section I have ever been sued for is the one I didn't do," Dr. Flamm said. "It's a sad but true situation." Not only is there a decreased chance of getting sued if a c-section is performed, but it's less time consuming to perform c-sections instead of waiting out long and sometimes difficult labor.

Leading medical groups such as the Centers for Disease Control and Prevention, National Institutes of Health and the World Health Organization have all spoken out against the increase, demanding the medical community investigate ways to lower the rate to 15 percent or below. ...Dr. Sandland thought she was doing just that.

In the decade she has delivered babies and cared for their mothers in New Hanover County, she has always had a rate below 10 percent.

"I've always maintained I'm a midwife with a MD behind my name," she said from her two-story Pine Valley home last week while preparing to move. "It's better for Mother Nature to decide when it's time, not the doctor. My philosophy is you don't interfere unless you really have to."

Fellow Wilmington obstetrician Dr. Joshua Vogel said though she was considered too set in her ways or a renegade by some doctors, he admired her talents to deliver naturally in situations when other doctors would have automatically pushed for a c-section. "She was a valuable asset for patients," he said.

Dr. Sandland said she became the target of the hospital's professional review and credentials committees. Because it is confidential by law, she could not legally discuss the peer review process.