Belly Tales

Let’s face it: the economy sucks right now.  We haven’t yet hit rock bottom, and it’s going to be awhile (probably a long while) before things begin to recover.  In the midst of this harsh financial reality, companies and industries are scrambling to find ways to save money.  Birth activists have been trying for decades to convince this country of the benefits of midwifery based on its safety and track record of better outcomes, not to mention improved client satisfaction, but hey, this is America—the only thing people really pay attention to in this country is the bottom line.  So maybe midwifery has finally found the argument it needs to affect actual change.  In the midst of one of the worst recessions since the Great Depression, NOW is the time to increase access to midwifery care because it’s excellent care for a heck of a lot less than what we’re currently spending on maternity care.

In early December, shortly after the nomination of Tom Daschle as Secretary of Health and Human Services (HHS), the Big Push for Midwives launched a campaign to get Mr. Daschle to attend a community meeting on midwifery and its advantages.  Per the change.gov initiative, discussions on healthcare reform will be occurring around the country between 12/15 - 12/31, and Senator Daschle has promised to attend a few of them in person.  Thanks to the Big Push for Midwives, he was invited to several heartland discussions, including this one in Lees Summit, MO.  I haven’t been able to find any updates or reports from this meeting yet.  I’m not sure if Senator Daschle was able to attend, but it’s definitley the sort of discussion he (and the Obama administration) should be listening to. (Was anyone actually able to attend that meeting?  If so, give us an update, please!!  I’ve been searching the internet for reports on the meeting, but I haven’t found any yet.)

As this excellent recent article in the LA Times (Midwives Deliver by Jennifer Block) points out, midwives deliver much safer care for much lower cost:

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.The Obama administration could save the country billions by overhauling the American way of birth.

It seems like instead of encouraging midwifery care, the opposite is happening.  Birth Centers around the country are closing at a rapid pace, and Medicaid has recently started to resfuse to fund birth center care:

Over the past few years, CMS (the federal agency that runs Medicaid/Medicare) has begun disallowing federal matching funds for state Medicaid payments for freestanding birth centers services. Birth centers have been recognized by CMS (and earlier, by HCFA) as a Medicaid provider type in State Medicaid Plans since 1987. Recently, however, CMS has disallowed such payment by several state Medicaid Agencies, including Alaska, South Carolina, Texas, and Washington State, claiming that it lacks clear statutory authority and direction to do so. CMS has directed its regional offices to stop federal payments to any state for birth center services.

As this article points out, this is going to cause a huge squeeze on birth centers around the country, and we’ll soon be seeing even more of them close unless something is done.  This is an urgent call to action.  The AACB has several resources on their website listing ways to contact your senators and let them know about this issue, including using this lovely flyer which lists all of the important talking points you’ll need when composing your e-mail or making your phone call (calls are preferrable, apparently, since e-mail is more likely to be lost in the midst of all the e-mails on the federal bail-out).  The reason this is so important is that Medicaid generally sets the standard for insurers.  If Medicaid stops insuring birth center care, other insurance companies will follow suit.  Birth centers are a crucial link in many communities, providing quality health care to diverse populations (including women on Medicaid - you only have to look at the work of Ruth Lubic and the Morris Heights birth center to appreciate that), and we need to keep as many of them open as possible.  Not only does it make great health sense, but it saves money too.

And here’s another great cost-saving suggestion: stop insuring preterm elective cesareans.  When I read this article I just about choked.  I can’t believe insurance companies are willing to pay for this when research has consistently shown that there are still a lot of complications with “near-term” infants (babies born between 34 - 36 wks) such as respiratory distress, jaundice, temperature instability (hypothermia), delayed brain development and feeding difficulties.  Forget the fact that a cesarean delivery is several thousands of dollars more expensive than a vaginal delivery; the real damage in this practice is caused by the increased number of preterm babies and the burden of care they demand.  Prematurity and NICU care accounts for one of the largest chunks of healthcare expenditure.  Even the March of Dimes is calling for a decrease in preterm cesareans.

I’ve always been consistently amazed that HMOs, managed care systems and Medicaid haven’t latched onto midwifery with more enthusiasm.  I wonder sometimes if this is because ACOG and the AMA are able to counteract the economic practicality of midwifery care with a tons of lobby money.  The economic angle isn’t anything new.  The Business of Being Born said the same thing in 2007, and Michel Odent, Ina May, Naomi Wolf, Suzanne Arms, Robbie Davis-Floyd etc. etc. have been saying the same thing for decades.  Maybe in the midst of the recession, the message will finally get through: midwifery care is better AND cheaper.

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

The BBC has put together an amazing series of articles on birth and maternal mortality in developing countries. This year, at the half-way mark towards the Millenium Goals set for 2015, we’re not even close to reaching the desired 75% reduction in maternal mortality. These articles explore the reasons behind these failures: everything from lack of US funding for the United Nations Population fund (ostensibly because the UNFPA doesn’t outlaw abortion) to the low status of women in developing countries, the low priority given to women’s health issues, unsafe drinking water, lack of access to medical facilities and skilled birth attendants, infection, poor nutrition and low birth weight.

“These women are dying not because we don’t have the means to save them, but because we (the world) have not determined whether they are worth saving.”

Why women still die to give birth

Action needed on maternal deaths

“They thought I was cursed” (article on maternal fistulas)

In pictures: fighting maternal mortality

Check out the older articles from 2005 and 2006 as well. Really excellnt, but really sobering reading.

Guess today is Catch-up From Chicago day. In addition to the very long post on the ACNM, MANA and CMs which I just posted below, I also wanted to “unofficially” post the 2007 ACNM Student Report, which I helped to draft at the annual meeting this year with approximately 20 other student representatives from around the country. This report is drafted annually by the student reps to summarize and present student concerns to the ACNM as a whole, and is published every year in the Quickening, the ACNM newsletter. As you might surmise from my post below, the issue I was most concerned about was the representation of CMs, which translated into joining the committee that was drafting the paragraph on Professional Issues, i.e. the newly proposed DNP and how this will affect midwifery education. I’m putting this behind a cut, because again, it’s a very long document and I’m not sure how many people are really interested in reading this in its entirety, but I have been wanting to post this up here since the convention for posterity, more than anything else. So, here you go: (Read on …)

I never had a chance to post much about my experiences in Chicago at the ACNM Annual Meeting in May, mostly because I was finishing up my semester at school, and graduating, and then studying for my board exams, and blogging was not a high priority. But I’ve been thinking a lot about my time at the convention, and there are still a lot of posts which need to be written about it. This is one of them. Where to even begin? The entire topic is enormous, highly political and daunting.

I get lots of e-mails from people who are very excited about becoming midwives, but aren’t sure how to go about it. They’re not sure which path to midwifery is the right path for them, and they’re confused about all the different options available to them. And rightly so: it’s highly confusing stuff! It took me years to get a basic understanding of all of this, especially many of the smaller nuances which you miss when you’re first learning about your educational options. And if we, the midwives and future midwives of America are confused about this stuff, just imagine how our clients feel, let alone your average American who’s surprised to learn that midwifery still exists as a viable modern profession.

Part of this confusion stems from the fact that in this country right now, there is no one standardized definition of a midwife, nor are there standardized credentials or certification processes. Instead of one standardized educational route for all midwives, there are two main routes you can take, and myriad ways to obtain differing degrees and qualifications. Instead of one professional title to designate you as a midwife, there are three legally recognized titles: CNM, CM and CPM. Instead of one national accrediting body for midwifery educational programs, there are two: ACNM and MEAC. Instead of one national board exam, there are two different exams administered by two different organizations: the AMCB (which administers the board exam to qualify as a CNM/CM) and NARM (which administers the board exam to qualify as a CPM). The acronyms alone are enough to make your head spin.

Just to give a quick overview (because I’m sure there are still many folks who’re confused about all of this), it works like this: the ACNM (American College of Nurse Midwives) is the professional organization of Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). Most of the members of the ACNM are nurses who then go on to obtain advanced degrees in midwifery (either a Masters degree or a certificate….usually a Masters), and are then credentialed through the ACNM. However, there are some members of the ACNM who are direct-entry midwives (i.e. do not have any prior nursing education or experience), who attend ACNM accredited midwifery education programs, and when they graduate are then credentialed through the ACNM and become CMs. In contrast, Certified Professional Midwives (CPMs) obtain certificates through midwifery-education programs which are accredited by the Midwifery Education and Accreditation Council (MEAC), and when they graduate, they are credentialed through the North American Registry of Midwives (NARM) and become CPMs. Like CMs, CPMs are direct-entry students, with no prior nursing education or experience. And because CPMs are not nurses, nor are they credentialed through the ACNM, they aren’t allowed to join the ACNM.

The professional organization which represents the interests of CPMs is the Midwives Alliance of North America (MANA), which seeks to represent the interest of every type of midwife in North America, including CNMs/CMs (even though their interests are already being respresented by the ACNM). While some midwives (well, CNMs/CMs) belong to both organizations, I think the majority of midwives tend to pick one or the other, if they even join at all (and just think how much further the profession as a whole could get if every midwife in the country actually joined their professional organization and paid dues, which could then be applied to projects and lobbying which actually benefits midwives and our profession. Sadly, of course, membership is never even close to 100%, which is just stupid. Membership in the AMA is just about 100%—I have never known a doctor who was not also a member—and just look at what a powerful and influential organization the AMA is—i.e., look what happens when a professional organization actually has money! Ahem.)

Now, there are so many problems with this I don’t even know where to start. Someone looking in from the outside could very sensibly say: well, don’t you think you’d have more power and more political clout and be better understood by the public and by other professions if all of you midwives just got together and decided on ONE standard definition, ONE standard credential and ONE professional organization to represent you? And of course, the answer to that would be a resounding YES! In countries around the world where midwifery has a very strong professional presence, and where midwives are not only highly respected but also deliver the majority of the babies in that country, invariably you will find that there is one unified professional organization for all of the midwives of that country, one standardized educational track and one credential. British midwives who are reading this, please correct me if I’m wrong, but I’m pretty sure that if you’re in England and you say “I’m a midwife”, no one needs to ask if you’re a nurse-midwife or a direct-entry midwife or if you have a Masters Degree or a Certificate. The profession of midwifery there has one standardized definition of what midwifery entails, one qualifying board exam, one credential, one professional organization and one standardized scope of practice. I’m sure this must really simplify things, and allow the profession of midwifery to move beyond issues of sorting out its own mess and instead tackle larger goals and issues and missions which are important to the entire profession, as a whole.

In America, because of all of the different credentials and the differing legal status of midwives from state to state, we’ve got an enormous range in our scope of practice. CPMs most often work in birth centers or homes, while CNMs/CMs can work in hospitals, birthing centers and homes. Depending on what state you live in, a CNM/CM may or may not be able to prescribe drugs, or admit private patients to a hospital. CNMs/CMs are required to work with a collaborating physician in order to practice legally (is this also true for CPMs? To be honest, I’m not sure. CPMs who are reading this, please let me know!). The scope of practice for CNMs/CMs can range from primary care to family planning to birth control to hormone replacement to basic gynecology. To be honest, I’m not sure if CPMs can do all of this as well (CPMs who are reading this, can you? Or is that a state by state thing, too?). In other words, it’s a hodge-podge mess. And maybe that’s just the nature of the game, given that America is a conglomerate of states, and because each state wields so much independent power, laws vary considerably from state to state.

However, the chance of MANA and the ACNM actually getting together and coming up with one unified plan for midwifery in this country seems very, very, very slim. And while there is a MANA/ACNM Bridge Committee that is working to keep a dialogue open between the two organizations, I doubt very seriously that I will see these two groups joining up in my lifetime. Part of the problem is that the interests of these two groups are too distinct and it’s hard to find the common ground, but I also believe that part of the problem is that there’s an undercurrent of disdain between members of both of these two groups, which harms every midwife in the country, collectively. I think that CNMs/CMs have a tendency to look down on CPMs as being under-educated, unacademic, tradition-based rather than evidence-based, and not very clinically well-informed, while CPMs have a tendency to look down on CNMs/CMs as being too interventionist and technocratic, too quick to view pregnancy from an medical/obstetrical lens, too eager to suck up to the AMA and/or the ANA, and having lost touch with the heart and soul of midwifery. The term “med-wife” gets bantered around a lot in reference to midwives who have apparently lost their soul and become too medically-minded, too quick to turn to drugs, induction, or pitocin, too much a part of the system. And of course, since CPMs don’t work in hospitals or have to manage hospital-based deliveries, “med-wife” is most often used to describe CNMs/CMs. There’s really no point in arguing which point of view is right; they’re both flawed, and so long as this continues, the profession of midwifery in America will continue to struggle.

However, this post isn’t really about the differences between MANA and the ACNM, and why the fervent dream of someday having just one professional organization in this country is most likely going to remain nothing but a dream. Instead, since I am a CNM and a member of the ACNM, my chief concern resides with issues within my own professional organization at this time. We’ve got to clean up our own house first before we can even think about moving forward. (Some of you may be wondering why I’m not also a member of MANA, and to be honest…that’s a really good question! I should be. More thought on this to follow).

When I was in Chicago this Spring, I was acting as the student representative from my midwifery program, and I had been charged by the direct-entry students in my program to make sure that the concerns and issues facing CMs were given a voice. I took this duty seriously, and when we were brainstorming ideas for topics to include in our student statement, I proposed that we ask the ACNM to make the recruiting of direct-entry students a bigger priority, and to encourage the development of more direct-entry educational tracks in existing ACNM accredited midwifery programs. This was met with a lot of resistence from the other students, and ultimately, this was dropped from our list of proposed topics (granted, there were more than 20 items on our brainstorming list, and many of them were dropped). Because there are so few CMs within the ACNM (at the moment, there are only a little over 50 CMs in the entire U.S.), the other student representatives felt that the student statement needed to focus on the issues of the majority. The consensus seemed to be that since CMs could only practice legally in three states (NY, NJ and RI), what was the point in encouraging more direct-entry educational options, especially in states where CMs aren’t legally recognized in the first place? To that I can only say: which comes first, the chicken or the egg? Legislative change is very slow, and it requires large numbers of people pushing for something in order to make it a reality. Until we educate and graduate more CMs, we will never have the numbers needed to actually demand that the CM be recognized in more states.

I was really surprised to learn that I was the only student there who came from a midwifery program which had direct-entry students, and which graduated CMs in addition to CNMs. Only a few of the other students even knew what a CM was, or were aware of the fact that there were ACNM-credentialed midwives who weren’t also nurses. There are only a handful of midwifery education programs in the country which are housed under a department other than nursing, such as a college of health-related professions or a department of allied health professions, and in these programs, since there is no need for a nursing prerequisite, direct-entry education is an option. Every other student in that room came from a midwifery program that graduated CNMs only, and most of these midwifery programs were housed within the school of nursing or were a part of the nursing department. And for the most part, these students didn’t see any problem with this. After all, they were all nurses, and were now going on to become certified nurse midwives. Why should it bother them if their midwifery program exists as part of the school of nursing? What’s the big deal? And why do we need more direct-entry routes of education anyway? If a direct-entry student wants to be a midwife so badly, why can’t s/he just go to nursing school and then on to midwifery school, just like they did? If you’re already a nurse, with boundless midwifery education options open to you, it just doesn’t seem that important.

This raises a lot of other issues as well. So long as midwifery programs are housed under the umbrella of nursing in this country, direct-entry educational tracks will not be widely accessible. But the larger issue is more of a philosophical one: if you’re a nurse who then goes on to become a nurse-midwife, what is your core identity? That of a midwife, or that of a nurse? How can midwifery fall under the jurisdiction of nursing, when as a midwife you are in a much different role from that of a nurse—the midwife diagnoses and makes management decisions and writes orders, which are then carried out by the nurse. How can nursing supercede midwifery? Is the profession of midwifery seperate and disctinct from that of nursing, with its own philosophy and culture and educational tenets? I would say, unequivocally, YES. And if that’s the case, is it possible to be a midwife without first being a nurse? Again, unquestionably, YES. While midwifery utilizes skills which are also used by nurses, the profession of midwifery predates the profession of nursing. When you look at other countries with a large and successful midwifery profession, you will see that there is either a direct-entry route which doesn’t first require a nursing degree, or else midwifery education is entirely seperate from nursing education, and you go to school to either become a nurse, or a midwife, but not both—and one is not a prerequisite for the other.

At the ACNM meeting this year, one of the very first suggestions made on the floor during the business meeting (i.e. the really big annual meeting where hundreds of members get together and vote on the really important stuff) was to change the name of the ACNM from the American College of Nuse-Midwives to the American College of Midwifery. This motion was tabled, but only after 10 minutes of pretty heated and strenuous debate (you could tell it would be a powder keg, if it was actually put forth as a motion), and this is not the first time that members of the ACNM have tried to change the name in such a way. It just goes to show that even within the ACNM itself there is a huge debate and very mixed views on this issue. Personally, I would be very happy with the credential of CM, instead of CNM. I wonder what would happen if more CNMs simply changed our credential to CM? After all, we are certified midwives, even if we are also nurses. Why should the nursing come before the midwifery?

The issue is coming to a head at the moment due to a new proposal made by the American Association of Colleges of Nursing (AACN), which has suggested the Doctorate of Nursing Practice (DNP) as the new entry to practice for advanced practice nursing by the year 2015. In other words, starting in 2015, if you want to be an advanced practice nurse (i.e. nurse-practitioner, nurse-anesthestist, and yes, nurse-midwife), you’ll have to obtain a Doctorate in Nursing Practice, rather than simply getting your Masters. As a student, this raises untold concerns, but from a professional point of view, it’s just as tricky. Since nurse-midwives are advanced practice nurses, will all CNMs starting in 2015 have to get a DNP? What if you’re a midwife, but you don’t want a doctorate in nursing practice? What if you’d prefer to get your doctorate in research, or international relations, or health policy? And where will that leave direct-entry CMs, who can’t obtain a DNP since they’re not nurses in the first place? What about the profession of midwifery itself, which is trying to move away from the shadow of nursing?

Requiring all future midwives to get a doctorate in nursing doesn’t seem to be the right way to go about this. Instead, I believe that the answer lies in midwifery education which is seperate and distinct from nursing education. The degree I obtained was a Masters in Midwifery, not a Masters in Nursing. I chose this route because I view myself as a midwife, period, not a nurse-midwife (even though yes, I am a nurse). Unfortunately, there are only a handful of midwifery education programs in the country right now which can offer a Masters in Midwifery rather than a Masters in Nursing, but I do think that Midwifery education would really benefit from this approach. Once obtaining a Masters in Midwifery is more widely available, more direct-entry students will be able to become midwives. From a self-preservation standpoint alone, this makes a lot of sense to the future of the ACNM.

Which brings me back to the MANA/ACNM divide. If the ACNM continues to ignore the direct-entry route and doesn’t work harder to provide more direct-entry options for students, where are all of those talented, bright, committed future midwives who aren’t already nurses going to go? Will they take the long way around, and go to nursing school in order to then go to midwifery school, or will they go to midwifery school right off the bat, via the more widely avaiable direct-entry route provided by MANA, and ultimately become CPMs rather than CNMs? There is obviously a large market for direct-entry midwifery, and many interested and talented women who are becoming amazing midwives without bothering to become a nurse first—and why should they? But it means that MANA and the ACNM are going to become even more polarized as the “direct-entry” professional organization versus the “nurse-midwife” professional organization, and so long as we have two seperate professional organizations, the profession of midwifery as a whole won’t get very far in this country. At a time when our country so desperately needs more midwives, period, and the ACNM itself is noting a shortage of qualified candidates for nurse-midwifery education, ignoring direct-entry students and not providing more direct-entry routes of education seems like shooting yourself in the foot. Direct-entry midwifery is the only way to get our profession out from under the foot of nursing, but so long as the ACNM continues to emphasize the nurse in nurse-midwife, our professional organization is never going to grow…and neither will the profession of midwifery in this country.

After signing off yesterday, I had some lunch then promptly attended three educational sessions in a row, two of which I paged. The first was entitled Cervical Ripening: What We Know and Why A Paradigm Shift is Needed for Reducing the Incidence of Preterm Birth, which focused on how our preterm labor treatments (tocolytics) are very utero-centric and concerned only with stopping contractions, while cervical ripening is often a much predictor for preterm labor. There is a lot of new research in this area, and new therapies aimed at counteracting cervical ripening might be more effective in stopping preterm labor than simply stopping contractions (which may, but often does not stop cervical ripening in any way). The speaker was very knowledgeable on her topic, which was her area of research and interest, but aside from presenting her own research, which is microscopic tissue analysis of the cervix under ultrasound to assess for markers of tissue disruption and increased water retention (precursors to ripening), there was not much which was immediately applicable to take away from her lecture. You get the sense, however, that in another 5-10 years, there will actually be drugs and assessment tools and treatments available to combat this aspect of preterm labor, which is very exciting.

The next educational session I went to was on sexual dysfunction, presented by a doctor who has spent years heading up a sex clinic in downtown Chicago and mentoring other medical and nursing students in sex therapy. While she had many, many (often sad, often hilarious) fascinating stories to relate, she really didn’t get into the nuts and bolts of sexual dysfunction in any great detail, at least not in any way that is immediately clinically applicable in terms of helping, counselling and treating couples with dyspareunia, anorgasmia, vaginismus, unconsummated mariages and premature ejaculation (although apparently you can use SSRIs, which notoriously have libido-killing side effects, to help delay and slow down men who have rapid ejaculation problems). Still, it was overall a fascinating topic, and really made me realize how little I know about sex therapy and sex counselling, which is indeed something a midwife should be pretty well versed in. While I certainly feel comfortable asking women about their sex lives, and discussing all aspects of sex and a person’s sexuality, specific treatments and counselling techniques are not at all in my repertoire, which is something that can be fixed with a little bit of reading and education.

The third educational session I attended was Menopause: Case Studies of Hormone Therapy, which was fabulous. I was astounded by how well the researchers knew the material. They made the very valid point that even though the Estrogen/Progesterone arm of the Women’s Health Initiative (WHI) was ended in 2002 due to the alarming increase in the rate of breast cancer, the other arms of the trial continued, and information is still pouring in from all sides, as well as from other studies that are now in progress. One of the speakers (Mary Brucker, CNM) termed it “research sushi”: after a large randomized control trial such as the WHI, you’re often left with more questions than answers, and in the ensuing years different aspects of the larger study are often chopped up (like sushi) into more specific questions and newer, smaller studies are mounted to try to tackle all of the questions raised. With hormone replacement therapy (HRT) at the moment, we’re apparently very much in the research sushi phase. It’s still a very grey, very unclear and ambiguous area, with very few clear guidelines or answers. While the WHI did a great job of scaring people so much that HRT is now often avoided at all costs (even when it can be very beneficial on a short-term basis for symptomatic relief of menopause), some of the information gleaned from WHI is actually, surprisingly saying the opposite. While the combined estrogen/progesterone arm increased the risk of breast cancer, apparently the estrogen alone arm of the study actually had no increased risk in breast cancer among the women treated with estrogen , and and a nearly significant decrease in risk (28% in the estrogne-alone arm, v. 34% in the placebo arm), which raises the question of whether all hormones are bad, across the board, period, end of story, or whether some hormonal therapy might actually have a very valid place in symptomatic relief (it also raised the question of what to do about women receiving unoposed estrogen without progesterone to balance it out, which has been shown to increase the risk of endometrial cancer). As you can see, very confusing stuff. They also delved into alternative treatments, such as the use of soy and phytoestrogens, Tibolone (which is used in Europe and actually had a worse Relative Risk for developing breast cancer than the combined and estrogen alone arms of the WHI), and compounded, bio-identical hormones, which also might not be the be-all-end-all cure that they are often touted as. Really, really fascinating stuff. I wish I was better versed in all of this, too, but I still find menopause and HRT very confusing.

Today started bright and early after a fairly late night dinner with a few other student midwives from Florida and North Carolina, mostly spent comparing our program experiences, mutually stressing about the board exams, and reviewing test questions that one of the students had from the test prep workshop she’d attended earlier that day. This morning I attended a great lecture on the Social Marketing of Breastfeeding, and how commercial marketing techniques can be very effectively used to market breastfeeding, especially when you break it down in terms of product, pricing, placement and promotion. She had all kinds of examples of ads from formula companies, which we then deconstructed in the class to root out the hidden, and often very sneaky and damaging hidden messages in them. Again, realizing how important language is: using the word “breastmilk repleacement” instead of “formula”, which makes it sound like a far inferior version of breastmilk, rather than a special, carefully planned, secret recipe which is just as good as breastmilk. We also talked about the importance of not only talking about the benefits of breastfeeding, but the risks involved with not breastfeeding. Again, none of this was new to me, but it was a very well put together and very concise presentation, full of good tips and suggestions, and it has really inspired me to work harder on my breastfeeding promotion and education (”selling” this amazing product—breastmilk!).

The schedule got a bit messed up, there are a few announcements on room changes and cancellations and switching of times, so the lecture on hormonal contraception counselling which I really wanted to attend, I missed. Instead, I ended up in a fascinating discussion panel on the horrific health disparities which still exist in our country, and the ways that midwives can work harder to amend these. We watched a small section of an upcoming PBS special entitled “Unnatural Causes: Is Inequality Making us Sick?”, which will air this winter in a 7 part series, and was incredibly eye-opening and terrifying in many of its implications. For example, the clip we watched demonstrated again and again that the areas of a county or city or state which have the lowest socioeconomic standing (which goes hand in hand with the highest crime rates) also have the highest rates of heart disease, pre-term birth, infant mortality, death by diabetes, hospitalization for asthma, lowest environmental standards, highest pollution and toxin exposure…the list went on and on. From the PBS website on the series:

Former U.S. Surgeon General Dr. David Satcher and his colleagues calculated that in 2002, 83,570 African Americans died who would not have died if black-white differences in health did not exist, a rate of 229 “excess deaths” per day. That’s the equivalent of one Boeing 767 being shot out of the sky and killing everyone on board every day, 365 days a year. And they are all Black. According to a by-now landmark study by Dr. Colin McCord and Dr. Harold Freeman, African American males in Harlem are less likely to reach age 65 than men in Bangladesh.

There are by now thousands of studies tracing the pathways by which racial and socio-economic status affect health. But there is virtually no popular media—no print, TV, nor web—that translate this research into forms that can build public understanding of how social policies are de facto health measures. As a result, the ‘common-sense’ wisdom remains that the poor and peoples of color get sick because they have unlucky genes, or they are just too lazy and undisciplined to to eat right, exercise and abstain frm drugs and booze. Similarly, it’s still widely believed that top executives who are dropping dead from heart and artery disease when in truth it’s their subordinates.

After watching the clip, we then moved into a very fascinating, (and very encouraging!) roundtable discussion. Midwives have always traditionally worked with underserved, indigenous populations, and it was amazing to hear about some of the changes and work that is being done around the country right now. You could feel the energy building in the room as people continued to come to the mircophone to speak. By the time the sesssion ended, the conversation had barely gotten started. Because the session is going to be repeated tomorrow, it was suggested that rather than starting over, we simply pick up the conversation again where we left off, which may or may not happen depending on how many people from today’s lecture attend the session tomorrow. In any case, though, I would watch the PBS documentary when it comes out, because it is going to raise A LOT of questions, and cause a media-world storm to descend on this long ignored issue.

Which now brings me to the present moment.  Time to find some lunch, and then sit in on an afternoon session review of the 2006 STD Guidelines (because, while I’m here, might as well attend lectures which will be useful on our board exam).  Tonight is the opening ceremony and dinner, followed by the long-awaited opening of the Exhibit Hall.  I can feel my money disappearing already.  Can’t wait!  Much more to come!

So, I arrived in Chicago last night to attend this year’s national ACNM annual meeting, which will be occurring from today, 5/25, through 5/31. Unfortunately, because I happen to be graduating on Tuesday, 5/29 (not so unfortunately, actually), I will be leaving the convention a few days early in order to get to Carnegie Hall in time. I’m flying out of Chicago on Tuesday morning at 6:00 am and arriving at La Guardia at 9:02 am. I need to be to Carnegie Hall by 11:00 am. Attention, forces of the Universe: please, please, please, let there be no weather delays, plane delays, traffic jams or other such late-making sundries on Tuesday morning (I’ve cut it a bit close)…gotta get to Carnegie Hall on time! (Yes, I have my graduation robes, mortar board and hood very unceremoniously stuffed into my carry-on backpack; if you happen to be at the graduation on Tuesday, I’ll be the one in the crumpled robes). However, the trade-off is that in return for crumpled robes, I get to attend this year’s ACNM annual meeting, even if briefly.

(I should have mentioned that I was attending this ages ago, but things have been a bit busy as of late, finishing up my clinicals (which are done!) and checking out of my program (also done!). I am now officially a GNM (graduated nurse midwife), which I will be until I pass the national board exam (hopefully sometime by the end of June, at the latest), at which point I will then (finally!) have the illustrious initials of CNM after my name. All a bit overwhelming at the moment—will have to think more about that a bit later.)

Aaaaanyway, let me tell you about Chicago! Excited doesn’t even begin to cut it. There are thousands of midwives and student midwives here. There are education sessions, workshops and meetings occurring practically round the clock. There is an exhibit hall the size of football field filled with all sorts of really, really nifty stuff that makes midwives all gooey inside, like pregnancy wheels and pamphlets on birth control and all the free pens in the world (free pens!) and loud and proud midwifery paraphernalia (will be coming home with new t-shirts and bumper stickers, I promise you), all the latest on breast pumps and prenatal vitamins and pharmaceuticals and midwifery and midwifery-related organizations, plus poster presentations on new research. More than that, though, is the opportunity to meet midwives from all over the country, network like nobody’s business, make new friends, discuss important issues, sharpen old techniques and knowledge and learn all the newest, latest, most up-to-date information, and decide on new national policy for the ACNM (the actual business meeting itself will be something to see, for sure). As the student representative from my midwifery program, I will also be meeting with other students from around the country to put together the student statement at this year’s meeting, which will be presented to the rest of the members at the business meeting. I am very excited to see what issues are important to the other student midwives of our country (I have a few ideas and input from my classmates about stuff we want to bring up, but it’ll be very interesting to see what other concerns and areas of interest are). I am so thrilled to be a part of all of this!

Anyway, it’s nearly 11:00 am, and I need to check in with the folks in Parlour B to figure out what workshops are still available to page (as a student, you can volunteer to be the page at various workshops, and therefore be able to attend the workshops for free, in return for paging—nice deal, huh?). I will be back online periodically to keep Belly Tales updated regularly, superfly live blogger that I am. More to come!

So, I’ve been a bit incommunicado thanks to the intensity of my clinical schedule, and the fact that last week was our first exam, and I was busy spending every spare minute studying for it (I’m very pleased to report that I did well on my exam, despite my deepest concerns regarding my sincere lack of study-time). In the meantime, lots of news has been breaking out all over the place, and I’ve been letting it slide. But no longer! Here’s what’s new in the world of women’s health and midwifery news:

First, Merck has recently stated that they’re going to stop lobbying for state legislatures to adopt universal HPV vaccine requirements, in part because of all of the sudden bad press and objections to their lobbying efforts and their fear that continued lobbying would undermine use of the vaccine. Meanwhile, questions continue to arise regarding Merck’s financial invovlement with Texas Governor Rick Perry’s campaign. The CDC has also recently emphasized that no additional warning labels will be placed on Gardasil and that so far, all of the side effects reported with use of the vaccine (mostly inflammation reactions at the injection site and fainting) are low risk.

Since we’re on the subject of vaccines, it appears that research is now targeting Chlamydia for a new vaccine.

A post by Miriam Zoila Perez, the latest NAPW guest blogger, is up on Feministing regarding Radical Doulas.

The Mommy Blawg has a great break-down of all of the latest midwifery legislation being proposed in various states, particularly legislation working to legalize that status of direct-entry midwives (CPMs).

And finally, via Women’s Health News, Tenessee Representative Stacey Campfield has recently proposed legislation requiring a death certificate for each terminated pregnancy in the state of TN, while simultaneously not requiring death certificates for each spontaneous abortion (miscarriage) that occurs in the state of TN. In most states, death certificates aren’t issued until the baby reaches certain gestational age and/or weight requirements, such as 20 weeks, or 500 gms. Since most elected terminations occur during the first trimester, and most spontaneous miscarriages also occur during the first trimester, does it not seem a bit hypocritical to issue death certificates for one and not the other? Naturally, the Tennessee Guerilla Women have plenty to say on the subject. And while Campfield continues to look foolish by trying to deflect attention away from the nitty-gritty details of his bill, NARAL Pro-Choice America has joined the fray by setting up an online form for the women of Tennessee to contact their state representatives.

Amanda from Pandagon and Jessica from Feministing, both of whom were lucky enough to attend the National Advocates for Pregnant Women Summit a few weeks ago, decided to continue to explore many of the issues and topics covered at the summit through weekly guest bloggers hosted on Feministing. The first two are up already:

Jill Morrison on Laws that Punish Pregnant Women and Priscilla Huang on Killing the Immigrant Body.

Both are fascinating and highly recommended reads. Can’t wait to see who the new guest blogger will be.

National Advocates for Pregnant Women just concluded its 4 day Summit To Ensure the Health and Humanity of Birthing Women in Atlanta, GA, this past weekend. This summit, one of the first of its kind, was organized by NAPW and NAPW’s director, Lynn Paltrow, to explore the grey area where pregnancy, birth and the law intersect. In our increasingly litigious society, the debate about reproductive choice and reproductive freedom is not limited only to the debate over abortion; women are constantly facing difficult decisions, constrictions and legal battles on a daily basis simply to be allowed to give birth where they want, how they want and when they want. It seems like one of the overt aims of this conference was to widen the terms of the discussion and to get the reproductive rights advocates talking with the pregnany and birth rights advocates, demonstrating how these two debates are really just different ends of the same spectrum, and how all womens’ rights are being constricted, whether they choose to have children or whether they choose to have an abortion.

The Summit program covered everything from the overbearing and disempowering birthing machine in this country to our culture’s rampant fear of birth, from the legal restrictions being placed on VBACs, contraception and abortions to the disturbing rise in fetal rights, where mothers with substance abuse problems are prosecuted for “child abuse” on behalf of their unborn fetus, instead of being offered the care and treatment they need….and so much more, more, more. I really wish I could have attended! NAPW even offered several bloggerships to a few of the lucky feminist, birth and reproductive rights bloggers who were able attend. Too bad we didn’t get a longer winter break; school started again on January 9th, alas.

It’s been absolutely fascinating reading the reports and thoughts of many of the bloggers who were able to attend. I’ve linked to a partial list of the blogs on the Summit, so that you can read for yourself. It’s almost as good as being there (although not quite).

Feministing: Semi-live blogging from NAPW Conference

Gymno: Sick Blogging

Gymno: Summit Day 1 (cont.)

Is there no sin in it: NAPW Conference is happening now!

bird in a bottle: More Lynn Paltrow love (and a prelude to Blog for Choice Day)

bird in a bottle: Language and Gender, Part Deux

bird in a bottle: Why I want to be Dorothy Roberts when I grow up

Angry Black Bitch: Thoughts inspired by sessions

Angry Black Bitch: Thoughts inspired by debates, particularly the VBAC v. cesarean delivery debate.

Pandagon: NAPW Summit kicks off

Pandagon: NAPW Summit: end of the 1st Day

Bitch PhD: Join this Organization

Women of Color: The first part of the conference

And even more from brownfemipower here and here and here, and finally: Midwives of Color.
Oh, and this is just too cute not to pass on.

And finally, a word or two from the demi-goddess herself: Lynn Paltrow’s article in the San Francisco Chronicle, On the Anniversary of Roe v. Wade