This meta-analysis (Maternal and newborn outcomes in planned home birth v. planned hospital birth: a metaanalysis) by Wax et. al. (also known simply as the ‘Wax study”) is not new.  It came out last September in the American Journal of Obstetrics and Gynecology (AJOG), but the reverberations of this controversial study are still being felt in the birthing community today.  As mentioned above, the flaws in this study have been discussed on numerous blogs and in numerous articles, so there’s no need to re-hash the entire argument here. (For further reading on this, though, check out the following links: Science and Sensibility, Our Bodies Our Blog, Science Based Medicine, Nature, ACNM’s response, Midwifery Today’s response).  To sum it all up, though, I quote from Michal et. al., Planned Homebirth v. Hospital Birth: A Meta-analysis Gone Wrong:

The statistical analysis upon which [the Wax meta-analysis'] conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

And that’s really the crux of the issue right there: ACOG has based their most recent home birth committee opinion paper on the Wax findings, despite the fact that the Wax study is so controversial, and has been so loudly contested.  ACOG seems to take the Wax study as gospel truth: “Published medical evidence shows [home birth] does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.” (i.e. the Wax findings).  But as you can see above, the Wax findings are anything but conclusive. Couple this with the fact that a recent study in the current issue of Obstetrics & Gynecology (ACOG’s very own publication, aka the Green Journal) found that two-thirds of all of ACOG’s practice guidelines have no basis in science, and we have a very serious cause for alarm.  As one of the letters to the Editor at AJOG pointed out in regards to the Wax Study,  this is the dangerous practice of communicating bad science to the public.  To quote liberally from this letter to the Editor:

These practices are unethical, causing harm through unfounded confusion and fear, and misleading policymakers and the public. The Singapore statement on research integrity represents the first international effort to unify policies, guidelines, and codes of conduct for researchers worldwide.⁴   Accordingly, the AJOG publication would fail on 2 counts: (1) poor quality of the study; and (2) author recommendations made beyond what the data support and outside of their professional expertise. Obstetricians are not the leading professional group in home birth and midwifery-led care, and should not reach policy conclusions in isolation. It is essential to use appropriate subject peer reviewers: in this case midwife and epidemiology experts in studies examining midwifery care and birth setting.

Obstetricians have never been the experts on home birth.  In my own personal experience, I cannot think of a single obstetrician who has even seen a home birth.  Nevertheless, as Melissa Cheyney writes in the  Huffington Post (Why Home Births Are Worth Considering), the Wax study is only serving to fan the flames between the obstetrical/ medical community and the home birth community (I purposely refrain from saying the homebirth/ midwifery community, because I feel like midwives can and do and SHOULD straddle the gap between the home birth community and medicine, offering high-touch, low-tech intervention as we do, and advocating for all women, everywhere, regardless of their birth choices or location of birth).  When home birth is seen as more dangerous than hospital birth by obstetrical “experts”, what then happens to the women and families who still choose to have a home birth?  Are they considered crackpots and lunatics endangering the lives of their babies?  What happens if they need to transfer to a hospital?  What happens if they need to transfer to a hospital but the midwife is reluctant to make the transfer based on the stigma and ostracizing treatment she and the family will receive in the hospital setting?  Will the barriers to midwives choosing to attend home births continue to rise so high that ultimately they can no longer provide this service? And if that happens, where does that leave the women who will still choose to have a home birth anyway, without any medical provider available to attend them?

So long as ACOG’s opinion on home birth continues to be based on poor science, we’ll continue to move further and further away from what this country truly needs: an integrated model of care, where women who choose home births and the midwives who serve those women are backed up by obstetricians and the medical model of care, allowing for safe transfers when needed without stigma, judgement or blame.

In New York State, CNMs/ CMs practice legally but CPMs do not.  I personally know of several friends who have had lovely, safe, wonderful births attended by CPMs in this state, but unfortunately these midwives did so illegally, with no back-up and no recourse if something went wrong.  Being charged with practicing medicine without a license is very serious, and especially tragic given that CPMs do have certifications, but are unable to obtain licences in various states depending on state legislation.   How wonderful it would be if CPMs were federally recognized the same way CNMs are (although the bitter politician in me wonders if the ACNM is going to welcome this legislation with open arms).  In any case, check out the MAMA campaign, and let’s keep our fingers crossed!

Last night I was working (at the HHC public hospital in Brooklyn where I spend a good deal of my time) and I received a phone call from a sister midwife who works with me at the same hospital.  She had just been contacted by a mutual midwife friend who had been contacted by a homebirth midwife who was in the middle of attending a difficult delivery last night and was considering a transfer to a hospital.  While I don’t know all of the details of the birth, I do know that the woman had been fully dilated for several hours already, and had been pushing without much success, and it was getting to the point where the homebirth midwife was beginning to think that a vacuum-assisted delivery might be necessary, hence the need to transfer to a hospital/ MD care.   What the homebirth midwife was most concerned about was the possibility of an MD at a hospital turning her in to the authorities for practicing without an official back-up physician/ written practice agreement.  Nevertheless, any woman in labor coming to any hospital is entitled to immediate emergency care, and cannot be turned away, thanks to EMTALA laws.  The problem is that if the midwife attending her does not have admitting privileges and/or a WPA at the hospital where they transfer to, she has limited authority and cannot necessarily continue to manage the patient.  In other words, the midwife would have to act as a monitrice (midwife at  home, doula in the hospital), which is disappointing and frustrating, to say the least, especially for the woman in labor who was relying on her midwife’s judgment and management.  It pretty much destroys the continuity of care between midwife and client if a transfer to a hospital is required.

And then, of course, there’s the relationship to consider between the midwife and the hospital she’s transferring to.  If the relationship has not been established in advance, the midwife is walking into a situation where she may not know or be familiar with the attending on call, may not have any say or influence in the continued management of the patient, and may actually be judged and excoriated (at the best) and potentially turned into the authorities (at the worst).  The hospital outlook towards women attempting homebirth, and the midwives who attend them, can be outright cruel.  I have heard MDs muttering under their breath before about how “criminal” and “dangerous” it is to give birth at home.  It doesn’t help, of course, that the women who transfer to a hospital are only transferring because something went wrong, or because they need something.  It means that the only type of homebirth that hospital providers see is a failed homebirth, which naturally colors their opinions on the success of the process.  They never see the beautiful, peaceful, uneventful, successful homebirths.  Instead, they can sometimes feel like they are being asked to “clean up the mess” made by homebirth midwives’ mismanagement, and the crazy people who are stupid enough to attempt birth at home.  The attitude of the staff at the hospital and the way they act towards the incoming transfer is crucial.  Either they can be respectful and positive, or judgmental and negative.

So, at the moment, we have plenty of people in New York city attempting homebirth with no back-up hospital to go to.  We have midwives who don’t know where or to whom to bring their patients if they need assistance.  We have couples trying to give birth who face potential castigation at the hospitals they may end up at.

I’m not really sure what happened to the couple last night.  I got a text from my sister midwife whom I work with who told me that the homebirth midwife and her clients would be heading our way, but they never actually showed up.  I was concerned because last night was actually really busy, and we didn’t have any extra beds to accommodate them.  I actually ended up delivering a beautiful 9 lbs. 6 oz baby in triage last night, and the other midwife I was working with had to do a delivery in the recovery room–both of these on stretchers and not actual beds, which is never ideal.  I know for a fact that we would have been kind and welcoming to any incoming homebirthers (we meaning the midwives…I can’t vouch for what the attitude of the doctors and nurses we worked with last night might have been, although I’d like to think that they would be pretty open and respectful, given that so many midwives work at our hospital).  In any case, the couple never showed up.  I can only hope that either they were able to successfully push the baby out at home without needing a vacuum, or else they chose to go to a different hospital than ours.

I can only hope that the homebirth midwives of New York City will be able to find back-up physicians at other hospitals and sign new WPAs/ get new admitting privileges soon, so a situation like this where a homebirth midwife is faced with such a difficult challenge doesn’t occur again any time soon.

And speaking of updates: Choices in Childbirth has just posted a follow-up to their initial action (Action Alert: Part Two), so we can continue to call and harass our legislators about how important this issue is.  Please call or write or sign the Midwifery Modernization Act petition now!  You can read the full text of the proposed Midwifery Modernization Act HERE.

Attempts to draft an 11th hour Written Practice Agreement between homebirth midwives and the Health and Hospitals Corporation (HHC for short–basically, the City’s public hospitals, which includes the hospital where I currently work) sadly fell through, although the latest update from Choices in Childbirth did add that HHC is still considering options.  Nevertheless, at the moment the crisis is unresolved, and this leaves women planning homebirth with no back-up options at this time.

What can we do about it?  First things first: SIGN THE PETITION in support of the Midwifery Modernization Act, which seeks to amend the Midwifery Practice Act in New York State so that having a written practice agreement in place with a collaborating physician is no longer required.  After that, you can continue to flood the Department of Health and Board of Education by making the following calls:

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 Mr. 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.

• 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!)

“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.

ACNM 2007 Annual Meeting
Student Report

Greetings from the student midwives to the board members, fellows and all attendees of the 52nd annual meeting of the American College of Nurse Midwives here in Chicago. Twenty–two representatives from midwifery programs around the country and Puerto Rico met together to discuss points of concern and share experiences. Our meetings were filled with energetic, articulate women of diverse backgrounds motivated to tackle the challenges facing us today and in the future of our profession.

We wish to express our thanks and appreciation to the College and all its members for the continued support of midwifery education in the areas of professional guidance, preceptorship, scholarship, and friendship. We especially want to recognize the hours of effort invested by those midwives who have selflessly volunteered their time of to serve as preceptors to midwifery students, and ask that they stand and be recognized.

We acknowledge the college’s recognition of and efforts to respond to the concerns expressed by last year’s student representatives, as evidenced by the addition of the student identification badge ribbons, the student section in the general conference program, the first-timers meeting, and the warm and welcoming attitude we have encountered by many members. However, we continue to be concerned about issues related to publicity and marketing, policy, professional issues, diversity, and communication.

Publicity/Marketing
With regards to publicity and marketing, an area of concern to us as students is the public’s widespread misconceptions regarding the existence, competence and scope of practice of nurse-midwives. We consider it important in maintaining and promoting our collective profession to address this problem via educational publicity and marketing campaigns. Though we recognize that ACNM already holds this as a priority, areas that may benefit from increased resource allocation include:
• Partnering with major corporations similar to the Johnson & Johnson® campaign to address the nursing shortage.
• Employment of a marketing strategist or consultant to meet the aforementioned goals.
• Proliferation of midwifery related content on websites, magazines or other media sources related to women’s health.
• Facilitating placement of nurse-midwives as spokespersons at media outlets.
• Creating a long-term plan for a general audience media saturation campaign
• Specifically target women’s health, labor and delivery and neonatal nurses with positive midwifery images and information to facilitate amicable professional relationships and potential recruitment.

Policy
Advocacy and politics are in the forefront of the minds of midwifery students. We celebrate the growth of our midwifery profession, but are sobered by the under representation of midwives in certain regions of the country, specifically, the central and south central states of region 5. Currently, less than four percent of the births in these states are attended by midwives. Many of these states lack the population density to evoke significant political change on the national level. The rural nature of these states also creates barriers to health education and access to midwifery services. To combat these issues, it is our responsibility to identify all of the professional allies of midwifery. It is imperative that we continue to collaborate and network with our partners to increase public knowledge within these communities regarding the utility of midwives. Some of the barriers to the midwifery growth include the lack of respect among health care professionals and our equity as autonomous health care providers. In order to elevate and support the midwifery model, we recommend that every midwife take the initiative to influence policy at local, state, and national levels. As we gain strength within the political arena we can decrease the compromises we are forced to make, decrease the thinned practice of midwifery, and increase the availability of midwives to our patients who deserve our care. Lastly, it is crucial that we take action to encourage the government to reimburse at a more comparable rate so that the underserved population has greater access to quality health care.

Professional Issues
The American Association of Colleges of Nursing (AACN) has proposed the DNP as the entry to practice for advanced practice nursing by the year 2015. As student midwives, on behalf of future students in years to come, we have concerns regarding our educational future. We have read and agree with the position statement on the DNP outlined by the Directors of Midwifery Education (DOME) in Volume 52, Issue 1, of the Journal of Midwifery and Women’s Health, (the January/Febuary 2007 issue). We affirm that Masters level education for entry to practice is more than adequate, but in light of the national trend towards the DNP, we recognize that as midwives we need to stay competitive with other fields. We would like to see continued and increased discussion and clarification within the ACNM regarding the way in which the DNP would affect the educational requirements of currently practicing midwives, current students and future students, particularly in terms of educational cost, both financial and temporal, and feasibility of training and preceptorship. More importantly, though, because nursing in not the sole pathway to professional midwifery certification, and because we have a professional identity which predates nursing, with its own theory and disciplinary knowledge, we as students would like to see alternative post-Masters educational options available to us. We urge you to continue to pursue the development of the Doctorate of Midwifery, that would include, but not necessarily be limited to, practice as the focus, as an alternative to the DNP, which will support and validate midwifery as its own distinct discipline.

Diversity
The student representatives have identified the diversification of the profession as a priority. We hope that our midwife population can reflect those that we serve—women of diverse race, ethnicity, country of origin, sexual orientation, economic status, age, religious beliefs and ability. We propose four strategies to achieve this goal:

• Encourage nurse-midwives of the above mentioned minority groups to attend career days at their local high schools and colleges, or their alma maters, in order to increase visibility and reach out to prospective students who can identify with the midwife as a professional role model.
• Encourage program directors to devote more time and attention in the curriculum to the healthcare needs of these minority populations.
• Encourage the proportion of workshops and sessions dealing with the healthcare needs of the increasingly diverse U.S. population.
• Advocate for the unique needs of diverse patients in the clinical area, through research generation and existing research utilization, and through direct political action.

Communication
Communication is a necessary tool in any successful organization, and is crucial in enabling student participation in various levels of the ACNM. We would like to propose three recommendations for consideration by the ACNM this year:

In the twenty-first century students across the country rely increasingly on internet sources for their information and communication needs. It is crucial for ACNM to accommodate this growing trend in order to both integrate the fresh energies of current students and reach out to prospective students interested in learning more about our profession. We suggest a student website be created linked to the ACNM homepage that is specifically created to foster student involvement and education about the College. We are aware that this suggestion was made during last year’s Student Report and were disappointed to see that such a development was not included in the recent improvements to the website.

This website would allow students from different programs to communicate with each other, the ACNM and the midwifery community. Additionally, it would serve as a resource for prospective students to learn about their educational options and contact student representatives from each program. Ideally this page would include:

• A School Directory including contact information of a student representative from each school
• Clear instructions on joining the student list-serve, along with a link to that site
• Opportunities to get involved in midwifery politics at the state and national levels
• A bulletin board highlighting updates in issues relevant to students
• A List of nurse midwives interested in precepting students

We are excited to be actively involved in this process.

We would also like to make a suggestion regarding the students in isolated regions of the country, distance-learning programs, or alone in their program. Many of these students are interested in participating in the chapter and/or state meetings and would greatly appreciate if these were web cast or recorded. This would benefit not only these students, but all ACNM members who are unable to attend meetings.

We appreciate having a voice during the conference, but to promote continuity we would ask the board to consider a permanent presence for a student or students on the board of directors to provide input and ideas. We are aware that this year, with new bylaws, we anticipate there will be a restructuring of the College, and we feel the division of education would be the most appropriate place for student representation. Other organizations such as ACOG, AMA, and Lamaze International have student members on their boards; we would like to see ACNM make this change as well. In addition, as we are dues paying members of the college and have our own unique voice, we seek representation through voting member status.

We appreciate this opportunity to present our concerns and recommendations in the student report. We look forward to your continued support and response.

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.

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!