The Man Behind the Curtain

This has been the most difficult post I have ever had to write.  For several days now, I have had a heavy heart and upset stomach because of what’s happening in our little state.  For those of you in other parts of the country – places where you have access to licensed, autonomous midwives and birth centers and home birth and everyone is working together nicely – count your blessings.  North Carolina is one of the worst states for birthing options due in large part to the leaders in our Medical Society.  For years now, they have fought any perceived encroachment on their scope of practice.  Visit their website and you will find legislative warnings about the danger of naturopaths and advanced practice nurses and, of course, those pesky “lay” midwives (check out the letter at the beginning of their 2012 Legislative Summary).  Their insistence that North Carolina should not license CPMs because home birth is unsafe is ironic considering it is their refusal to license and regulate midwives that is currently making home birth unsafe.  If we don’t offer a path to licensure for midwives practicing at home, how can the families, who are legally able to choose to give birth at home, know if the women practicing are safe?  When I asked this question at our meeting with the Medical Society, Haywood Brown looked me in the eye and said, “Go to the hospital.”  These are the same folks who also put pressure on Dr. Henry Dorn to stop backing CNMs practicing home birth in our state, resulting in hundreds of families loosing their care provider mid-pregnancy.

But all this talk about the ‘safety’ of home birth is smoke and mirrors, y’all.  The physicians want the conversation to be about home birth because then we don’t have to talk about what’s going on inside of hospitals right now.  Let’s talk about the fact that the United States currently ranks 50th in the world in maternal mortality, and we rank 35th in the world in infant mortality.  Is it really all that safe to give birth in hospitals?  If one in three women are being subjected to a surgical birth, I like my odds better elsewhere.  Why do you think the number of women who are choosing to give birth at home is on the rise in our state?  Women are suffering from Post Traumatic Stress Disorder because of what is happening to them in hospitals.  Women are using words like, “coerced” and “bullied” to describe how they feel they were treated in labor.  But as long as they can keep the focus in the media on what’s happening at home, they don’t have to answer for their own bad outcomes.  Not to mention the fact that if a baby or mother dies in a hospital, the physicians and hospitals have very expensive lawyers to settle lawsuits and millions of dollars to pay the families.  And then the families are told they are not allowed to discuss their bad treatment with anyone.  Ever.  So the bad behavior continues and the public remains ignorant of the truth.

The-Bully-the-Bullied-and-the-BystanderLet’s go back to the word “bully” for a moment.  Last year, my daughter was experiencing some bullying at school so I bought The Bully, the Bullied and the Bystander by Barbara Coloroso.  If you work in the birthing world, I highly recommend this book.  As I read the book, I realized that if you replace the word ‘bully’ with ‘provider,’ the word ‘bullied’ with ‘patient’ and the word ‘bystander’ with ‘support staff’ she could have easily been describing what’s playing out in maternity wards all over our country.  Her solution is not simply to deal with teaching the bully how to be nice or teaching the bullied how to stand up for themselves.  This dynamic will only change when we teach the bystanders not to tolerate bullying and to speak up for the bullied.  When I google searched the word ‘bully,’ I followed the link to the Wikipedia website and found that there were links to separate pages titled “Bullying in Medicine” and Bullying in Nursing.”  Hospitals are a culture of bullying, so much so there have been studies to try to understand why.

Maternity care in this country is such a mess, we have entire websites and organizations dedicated to try to make it better (ImprovingBirth.org, The Unnecesarean, CesareanRates.com, Childbirth Connection, Coalition for Improving Maternity Services, Karen Brody’s “Birth” on Labor Day movement, Choices in Childbirth, My Best Birth, BirthNetwork National).  The only folks who seem to be uninterested in working on making things better are the physicians.  Rather than asking what women want, and striving to provide that, they are out there fighting to take away the very services women want.  Look at what’s happening in Texas and South Carolina right now.  They are actively trying to take away access to licensed midwives, and they are trying to take over control of birth centers.  It’s time to stand up to the bullies.

Next week, join us in Raleigh outside the General Assembly as we demonstrate our frustration at the lack of leadership in the Senate.  We demand due process.  The citizens of our state have made it obvious to their elected officials what they want.  The physicians in our state do not get to decide what happens in our legislature.  We will be protesting on Jones Street from 10 to 11am Tuesday, Wednesday and Thursday.  Now is the time to take a stand.  Now is the time to send a clear message to the Med Society and the legislators who value campaign contributions more than the wants and needs of the people they govern.

Just to be clear. . .

love midwivesI love CNMs as much as CPMs.  My post last week was written with a broken heart because I tend to be quite Type-A and have very high expectations of people in my life.  Sometimes, my tendencies toward perfectionism leave little room for mistakes committed by others.  Just ask my husband!  I understand why NCACNM wanted to pass their bill this session – last year, almost all of the home birth CNMs in our state lost their backing physician leaving hundreds of families scrambling to find a care provider.  If they can get rid of the physician’s signature requirement, the CNMs practicing home birth can continue serving their families.  This is hugely important to our organization as well – read more about our attempts to help this situation here.

But I also want to explain a bit about why I chose a CPM and why I feel particularly passionate about obtaining licensure for them in our state.

When I got pregnant in 2004, I did not know about home birth.  I just knew I was pregnant and uninsured and new to my community.  I had not found an OB/GYN for my well-woman care (did not know about midwives!), so had to start making phone calls to find someone to care for me and my tiny, growing baby.  Each of the practices I called informed me they were not accepting new patients, except one.  The secretary at this practice said they would be happy to see me, until she found out I was uninsured.  “We require 10% of the doctor’s fee at your first visit.  His fee is $6000, so you will need to bring $600.”  Now at the time, our rent was $700 and my husband was unemployed.  Where were we going to come up with that kind of money?  I was distraught and beginning to feel that we had made a huge mistake, trying to start a family when we couldn’t afford to pay for a physician.  I began looking up any and everything I could on-line about birth.  And that’s when I discovered something that changed my life – pictures and a blog about a woman giving birth under a tree in California.  With midwives.  Whoa.  Wasn’t that unsanitary?  Dangerous?  But the story this woman wrote was so beautiful and compelling, I began looking up the now new term “home birth.”  I found a site called nchomebirth.com and discovered that in order to find a midwife practicing home birth in N.C. I had to enter my personal information and wait for a phone call from some stranger.

Once I got a phone call, I found out that this particular midwife lived almost 2 hours away but came to Wilmington to do pre-natal visits once a month to help assist families have the type of birth they wanted.  No one else was helping families choosing home birth on the eastern side of the state.  She explained that she had no license in our state, but at the time I did not understand the implications.  I just knew I did not want to have my baby in a hospital.  And did I mention how affordable she was?  She was charging $2200 for all of my prenatal care (each visit lasted an hour), and the birth and several post-partum visits.  And her apprentice would teach us the Bradley method as a bonus.  Wow.  If I had chosen the physician, my visits would have lasted about 5 to 10 minutes and his fee would not have covered the birth or post-partum care.  Not to mention all of the hospital facility fees and incidental charges.

After 25 hours of labor, we saw meconium in my amniotic fluid so I decided it was time to head to the hospital.  That was when I understood why not having a license was not okay – my midwife had to pretend to by my doula.  When the hospital staff asked if I had received any prenatal care, my husband said, “Yes.”  But when they asked for our records, we could not provide any.  Everything worked out – Katherine was born about 30 minutes after  we arrived (20 minutes of pushing).  But it became quite clear to me why we needed to have licensed midwives in our state.  We need continuity of care.  My midwife needed to be able to hand my chart to the physician so my husband and I could have continued laboring together.  Instead, he was busy filling out paperwork and getting the third degree from the hospital staff.

My second daughter was born at home with the midwife’s apprentice from my first birth.  She had passed her CPM certification and opened her own practice.  Rose was born after a quick 4 hour labor, just in time for lunch!  It was perfect, peaceful and I could not have imagined a more beautiful birth.  I became fascinated by the kind of care she was providing, and by the fact that she was willing to risk being arrested in order to continue practicing.  She agreed to let me follow her to births to film a documentary.

At each of the three births I had the honor to attend, I documented something that I had not noticed during my own birth.  While the woman was laboring, my midwife and her apprentice sat patiently watching – encouraging the woman, offering suggestions, checking heart tones – doing all of the kinds of things one would expect a birth attendant to do.  But there was something else going on, something much more subtle.  Several times throughout the labor, my midwife would look across the room at her apprentice and make eye contact.  No words were exchanged, but the apprentice would leave and return with something that the midwife clearly needed at that moment.  This is the art and craft of midwifery, and what I fear is going to disappear from maternity care if we fail to ‘legitimize’ the CPM credential in our state.

There is a type of knowing that cannot be quantified.  I have read many books about it – In a Different Voice by Carol Gilligan; Women’s Ways of Knowing by Belenky, Clinchy, Goldberger and Tarule; Sacred Pleasure by Rianne Eisler.  Pregnancy and birth are uniquely feminine experiences, and therefore belong largely to women.  Midwives are, and have been since the beginning of time, Wise Women.  Here is Psychology Today’s definition of ‘wisdom':

It can be difficult to define Wisdom, but people generally recognize it when they encounter it. Psychologists pretty much agree it involves an integration of knowledge, experience, and deep understanding that incorporates tolerance for the uncertainties of life as well as its ups and downs. There’s an awareness of how things play out over time, and it confers a sense of balance.

Wise people generally share an optimism that life’s problems can be solved and experience a certain amount of calm in facing difficult decisions. Intelligence—if only anyone could figure out exactly what it is—may be necessary for wisdom, but it definitely isn’t sufficient; an ability to see the big picture, a sense of proportion, and considerable introspection also contribute to its development.

I believe that midwives who are free to practice the Midwives Model of Care “experience a certain amount of calm in facing difficult” situations.  This allows them to have a “tolerance for the uncertainties” of birth.  When midwives truly sit with woman, they are able to sense what is happening with her and her baby.  They do not need to see a machine in order to know when a woman is experiencing a contraction – they feel it.  I know because I could feel it, too.  And it was really intense and wonderful.  But I can see where some folks might not be aware of the fact that they can ‘feel’ what others are feeling, and simply know that being in the presence of a birthing woman feels uncomfortable.  I can also see where there would then be a need to control that experience and make it less uncomfortable.

I am fully aware that much of what I am writing about here is considered ‘hippy-dippy, voodoo nonsense.’  But this is my truth and I feel compelled to tell it.  When women receive care from a midwife, when they are allowed to experience birth on their own terms, to feel all of their fears and finally embrace them and surrender to something more powerful than themselves, they are transformed.  Through both of my births, I discovered that there is tremendous power in being vulnerable, in giving up the need to control everything.  The experiences we have in life and the emotional responses we have to them cannot be proven, but does that make them any less true or real to us?  This is the element that is at the core of what’s wrong with maternity care to me – the medical model allows no room for the emotions of birth.  The objective is logical – deliver a healthy baby from the mother.  There is no consideration for the way the mother feels about her treatment.  I prefer the holistic approach of the midwives model, and I will continue to fight to preserve it.

They did WHAT?!

midwivesOye.  I hate that I even have to write this today, but here it is – the Certified Nurse Midwives in our state have filed a bill in the house (H204) that will increase the penalty for non-nurse midwives practicing in our state.  So, if the CPM bills that are currently in the Senate do not become law this legislative session and the CNM bill does. . .all of the non-nurse midwives practicing in North Carolina could be charged with a class one misdemeanor.  Currently, the charge for practicing midwifery without a license is a class three misdemeanor.  The CNM bill, as it is written, adds the charge of practicing medicine without a license.

When NCFOM Legislative Chair, Lisa Fawcett, contacted the NC affiliate of ACNM regarding this language, she was told by their lobbyist, “Thanks for passing this along. The section Lisa cited would have the effect of increasing the penalty for practicing without a license from a Class 3 to a Class 1 misdemeanor. It was added to satisfy a request from the sponsors that the bill increase the penalty for those unlicensed providers who continue to practice midwifery in violation of the law.”  Uh, yeah.  There are midwives in our state practicing without a license, but not for a lack of trying.  The North Carolina Friends of Midwives have been trying to get legislation passed to license and regulate CPMs for the past 6 years.  I know because I have been helping them, and because my midwife closed her practice to focus on lobbying efforts.  She has spent the last three years driving two hours to Raleigh three days a week to educate legislators about why we need to license and regulate CPMs in North Carolina.  These women who are “practicing midwifery in violation of the law” are serving a growing population of families who want to give birth at home.  And they do so at great personal risk because they know it is a woman’s basic human right to decide where and with whom they give birth.

What makes this situation even more disappointing is the fact that the leadership of NCACNM know the history of the fight to get licensure for CPMs in our state (for a thorough recent history, watch from about 46 minutes):

In January of 2010, “Where’s My Midwife?” hosted a quarterly meeting for NCACNM and invited Wendy Dotson to speak.  Wendy is a midwife in Virginia who told the story of how the Friends of Midwives in Virginia were so close to passing legislation to license and regulate CPMs, that the CNMs decided it was time to lift the physician signature requirement from their licensing language.  Wendy told how the Friends of Midwives asked the CNMs to wait until they got the CPM bill passed, then they would turn their grassroots efforts to helping the CNMs get the job done the next year.  And that’s exactly what happened – in 2005, the CPM bill passed and in 2006 the CNMs got what they wanted as well.  Win/win.  NCFOM offered to do the same thing here for the CNMs – let us get the job done, then we will help you.  Instead, NCACNM decided to do what was best for themselves, not what was best for the families of our state.

So, why did the CNMs in North Carolina feel that NOW was the right time to file their bill at the General Assembly when NCFOM has been working so hard to educate the legislators and get the votes they need?  Why?  And why did they add language that would make it worse for their sister midwives if they get arrested?  I feel partly responsible for all of this because I suggested that the leadership from all of the organizations sit down and come up with a plan to work together and never followed through.  Could a meeting have prevented this terrible turn of events?  I’m not very good at confrontations.  The thought of getting all of those adults in one room and having to ask them to act like grown ups was unsettling at best, and downright depressing at worst.

But I think what is most disturbing to me is the trend with nurse midwives to side with physicians to rally against non-nurse midwives.  Why would you try to be more pleasing to the very people who are constantly putting you out of practice and creating restrictive policies to limit your ability to care for women?  Why do you continue to increase your educational requirements?  To be more pleasing to the physicians?  Does more education really make you a better care provider?  I would argue that it most certainly does not – 90% of our population are served by obstetricians and their statistics are horrifying.  The fact that NCACNM did not turn around and leave any legislator’s office that would require them to increase the penalty for unlicensed non-nurse midwives is downright disturbing.  It makes you the worst kind of practitioner – one who thinks of yourselves first.  How will that translate to the kind of care you provide your families?

“Where’s My Midwife?” seeks to increase access to ALL midwives in ALL settings.  We ask that the Certified Nurse Midwives in our state revise their bill to eliminate the language that is so divisive and dangerous to their sister midwives.  We need to be working with each other, not against each other.  If you agree, let them know (from the NCACNM website):

acnm

Our North Star – Part 2

nativemama6So, if a birth center in every community is Our North Star, how do we get there from here?  I’ve got some ideas about that!  The first (obvious) step is to have legal, autonomous midwives in all 50 states.  We need Certified Professional Midwives, Licensed Midwives, Certified Midwives, Certified Nurse Midwives, all of them practicing in every setting!  Midwives at home, midwives in birth centers, midwives in hospitals!  The key here is the word autonomous, because, as Gloria Lemay pointed out in this blog post back in 2009, when midwives are working in a broken system that requires them to conform to outdated practices they are not truly practicing midwifery.  And that’s why we must all join forces and stand together in opposition to those who would deny us access to the kind of care we deserve.

In North Carolina, we have no path to licensure for CPMs and CNMs must obtain a physician’s signature in order to receive a permit to practice.  As many of you know, the North Carolina Friends of Midwives (NCFOM) have been working tirelessly since 2007 to get legislation passed to license and regulate CPMs.  Last week, they introduced two bills in the Senate – SB106 the Home Birth Freedom Act and SB107 a Decriminalization Bill.  If you live in North Carolina, please become a member at NCFOM.org to receive updates and legislative calls to action.  We need every voice to be heard, we need to be loud and firm.  We want access to midwives in every setting.

In Texas, they had what I would consider one of the best birthing environments in the country. . .until last week.  Turns out, there is a new legislator (who happens to be an anesthesiologist) that has a bill in drafting that will re-write the language in the birth center regulations.  The changes would eliminate Licensed Midwives from the regulations entirely and would put the physicians squarely in control of birth centers.  The bill has not been filed, but the fact that it has even been drafted is disturbing to say the least.

And then, there’s South Carolina. . .a very similar bill was filed by another physician limiting the ability of CPMs in that state by requiring that they have a supervising physician (sign petition here).  It would appear that the physicians in this country are going on the offensive in a ridiculous turf war over women’s bodies!

But who could blame them, really?  Let’s look at what has transpired over the last few years:

  • Last Labor Day, over 10,000  rallied in cities all over the country thanks to the incredible efforts of Dawn Thompson and the folks at ImprovingBirth.org who called for folks to question elective cesareans and early elective inductions.
  • On September 20th, One World Birth‘s film “Freedom for Birth” was viewed by over 100,000 people at 1000 screenings worldwide.  The film told the story of the ruling at the Hague that determined it is a woman’s basic human right to choose where and with whom she gives birth. It also told the story of the amazing mamas in Canada who marched to the hospital and asked the question “Where’s My Midwife?” in order to get the hospital to grant privileges to their local midwives.
  • Women in Australia are marching and organizing to demand access to home birth.
  • In January, the National Birth Center Study II was published revealing that women who are seen by midwives in an out-of-hospital setting only experienced a 6% c-section rate.
  • With 27 states now licensing CPMs, we have officially crossed the 50% mark.  According to the Big Push for Midwives website, there are currently 13 states working on legislation to license and regulate CPMs (NC, MD, IN, MD, DE, AL, MS, IL, SD, IA, MI, MA, NE).
  • And let’s not forget the Time Magazine article “Bitter Pill: Why Medical Bills are Killing Us” by Steven Brill that came out last week which exposes the unchecked greed driving prices in the hospital ever higher.
  • Right now, maternity care professionals are holding a conference in DC called “Workshop on Research Issues in Assessment of Birth Setting.”
  • Birth Centers like Jennie Joseph’s The Birth Place in Florida is reversing racial disparities by using the JJWay – treating women regardless of their ability to pay and helping them navigate the system in order to get the care that they need.

In this birth activist’s humble opinion, never has there been a better time to march in the streets and start a revolution.  If we hold the Birth Center as our North Star, the true way forward for maternity care, we can rise up and demand that the ‘powers that be’ begin to treat women the way they deserve to be treated – with respect and with scientific, evidence-based practices.  If you want to be a part of the revolution, join us in July at the Second Annual Birth Activist Retreat in Utah.

Our North Star – Part 1

On January 31st, the Journal of Midwifery and Women’s Health published the National Birth Center Study II, and the interwebs lit up with happy blog posts (like these: Childbirth Connection, Evidence Based Birth, Birth Without Fear, Science and Sensibility, ImprovingBirth.org, and our own).  The American Association of Birth Centers also created a ton of beautiful graphics to share on Facebook, touting the incredible findings of the study, like this one:

6%BC

Birth Centers have been serving low-risk women for the last 35 years, and this new study shows that they set the bar pretty high for everyone involved with birthin’ babies.  With a C-section rate of only 6%, clearly midwife-led care is the gold standard.  This study basically proves, yet again, that when women are treated with respect and placed at the center of their care they can give birth to their babies just fine, thank you very much!

Last fall, my husband and I had the distinct pleasure of traveling to Pennsylvania to work on the Birth Center Impact Video Project.  We recorded interviews with folks in the communities surrounding two of the oldest birth centers in the USA – The Birth Center in Bryn Mawr and Valley Birth Place.  Each of these birth centers has been serving families for over 20 years!  A second film crew visited Birth Care in Bart, PA and Reading Birth & Women’s Center.  We edited some of the footage into four short films that depict the  Archetype of the Birth Center (videos below).

Imagine a world with a birth center in every community!  A world where all women began their pregnancy with midwives who viewed pregnancy as a natural life-process and helped each woman make choices regarding her pregnancy and birth that were best for her and her family.  Because moving birth away from the medical model is not simply about lowering the C-section rate and saving money, it’s about helping women to reclaim birth as a sacred, powerfully personal life experience.  In my opinion, the birth center model represents our North Star.  Let’s start moving maternity care in that direction!

The 4 Facets of the Birth Center Archetype in a community. . .

The birth center is:

Sanctuary where mothers give birth

Learning place for intimacy, birth, & family

Supportive community for women & families

Midwife’s place of business

New Study Highlights the Tremendous Benefits of Birth Centers

AABC_Logo_2011_RGB-LGEveryone knows that WMM? loves birth centers. Birth centers are a place where women can fully experience the midwifery model of care. Pregnancy and birth are viewed as normal, healthy, yet important life events. The peaceful, home-like atmosphere allows for woman centered care. And, of course, birth centers are generally operated by midwives and we love midwives! A new study shows that this model of birthing provides huge benefits. The National Birth Center Study II was conducted by the American Association of Birth Centers (AABC) and published in the most recent issue of the Journal of Midwifery Women’s Health, the official journal of the American College of Nurse-Midwives (ACNM).

The birth center study included 15,574 women who received care in 79 midwife-led birth centers in 33 U.S. states from 2007 through 2010. Out of the 15,574 women included in the study 84% gave birth at their intended birth center. Only 16% had to transfer care to a hospital and of those transfers the vast majority were for non-emergency reasons. Fetal and newborn mortality rates were low (0.47/1000 births and 0.40/1000 births, respectively) and were comparable to those in low-risk births in hospital settings. There were no maternal deaths. Fewer than 1 in 16 of the study participants had a cesarean birth. That statistic is so amazing that I want to write it again and again: only 6% of women giving birth at a birth center ended up needing a surgical birth!!! This is big news. In 2010 the U.S. Cesarean rate reached an astounding 32.8% of all births. If this statistic is adjusted to reflect only a population that similar to the low risk women giving birth at birth centers, it is still an estimated 24%. That means 1 and 4 healthy, normal pregnant women end up needing surgery. If these women received care at a birth center most of them could avoid have avoided that costly intervention.

bcbabyOn the topic of cost, the study highlights significant financial benefits as well. Given lower costs in the birth center setting as well as low rates of cesarean birth, the 15,574 births in this study may have saved more than $30 million in facility costs alone based  on Medicare/Medicaid rates, not including additional savings in costs of other providers, anesthesia, and newborn care in hospital settings. If even 10% of the approximately 4 million U.S. births each year occurred in birth centers, the potential savings in facility service fees alone could reach $1 billion per year. In addition, U.S. spending on maternity care could decline by more than $5 billion if only 15% of pregnant women gave birth via cesarean. That is some serious savings!

The benefits of birth centers are too significant to ignore. This birth option needs to be available to women everywhere. Birth centers are the gold standard in maternity care.

Anna is Pregnant – Episode 2, Midwifery Magic

Erica_pic2I have been having practice contractions forever, at least my whole last trimester. As my guess date approaches– tomorrow!– they have been increasing in intensity and frequency. I have even had a few that have made me think, “humm, will tonight be the night!?” Last night seemed to be one of those nights, so I called my dear midwife in the early evening just to give her an update. I knew I wasn’t in labor, but the slowly increasing activity seemed worth noting. She replied with an offer to come to my house just to check me.

Now I am someone with a history of shorter labors. My last one was about three hours; and only half of that time was I really sure that it was the real thing. So having someone who is willing to drive all the way to my home in the evening just to give me a bit of extra information and reassurance, is deeply comforting. This is part of the magic of midwifery care. For me this aspect of truly personalized care is what is most important.

Stay tuned my next blog will probably have a baby in it, maybe tonight will be the night!