Sunday Night Reading List

 As my personal life has been a bit busy lately, I am just popping in after a long absence to post some links worth reading.



Science Blogs on Dr. Amy Tuteur's calling out the homebirth movement denialism.

Harvard Magazine on the C section rate and finding balance between safety and the desire for a natural birth experience.

Suspended midwife charged after breech baby dies during homebirth in NJ

Lazy Birthing Manifesto on Jezebel

Cooling technique saves life and brain of Isle of Wight homebirth baby rushed to hospital.

Toledo Certified Nurse Midwives celebrate twenty years!

Navelgazing Midwife on the Brewer Diet and Pre-Eclampsia

No Explanation Needed. Carry On!

Great piece on Jezebel about the conflict between the bodily autonomy of women and the increasing pressure placed on mothers to breastfeed. 

 Are we on the verge of a backlash?   I hope so.  Sure, breastfeeding is great.  But there is nothing wrong with formula feeding in the developed world, either.  If the water is good, your baby will be just fine on formula.

 Yes, really.  My parents were both formula fed.  And they managed to get into prestigious universities and study things like economics and Medieval history.  My mother even marched against the Vietnam War.  (My father was considered fit enough to join the Army, too!)

Until recently though, I always felt that I had to justify my choice to use formula for my child.  I hated the judgmental stares and the pointed questioning:

"Why aren't you breastfeeding?"

I thought I owed other mothers an explanation.  A confession.  I thought I needed to be absolved of maternal sin.

Until I heard this story.

A friend was at the pediatrician's with her kids.  When she began bottle feeding her baby, another mother chastised her and demanded to know why she wasn't breastfeeding. 

My friend looked at her and said, "I don't owe you an explanation."  Then she turned back to her child and continued feeding him with a bottle.

"I don't owe you an explanation." 

One of the most freeing and empowering things I've heard in years.

You don't need to explain to me why you are breastfeeding your toddler.  And I don't need to justify the cans of Enfamil that used to fill our pantry. 

We are adult women making adult choices about our own children.  As long as your kid is getting his nutritional needs met and is physically and emotionally safe, and you aren't putting other people in danger, you don't owe any one an explanation for your parenting choices. 

So, don't worry about breast v. bottle.  Do what you need so that you can be the best parent to your child. 

Midwives: Bringing It On Themselves

As a Michigan taxpayer and mother, I strongly support Senate Bill 1208, The Michigan Midwife Bill.  For too long, Michigan midwifes have operated in an a-legal state, attending births with less oversight than your hairdresser.


SB 1208 provides moms with safety and choice.  Women who choose out of hospital birth will have the benefit of a beautiful birthing experience attended by a clinically educated and accountable midwife who puts the safety of mom and baby first.   What could be better?

If midwives want Medicaid and insurance reimbursements, it is time for them to be strictly regulated.  It is time for a consistent scope of practice.  It is time for consistent educational standards.  It is time to report outcomes. It is time for accountability.

It is time for midwives to stand up for women and babies.  It is time to stop claiming every piece of legislation designed to protect human lives is a tool of an oppressive patriarchy. 
  
The truth of the matter is that the midwifery movement has brought this situation on themselves. 



1. Not transferring high risk clients to obstetrical care.

2. Describing  high risk conditions as "variations of normal" in order to promote an agenda that all birth is "as safe as life gets" regardless of the medical needs of individual mothers and babies.

3. Refusing to set concrete and consistent educational standards for classroom and clinical training.

4. Refusing to require hands on clinical training in emergency births.

5. Fighting every attempt to hold midwives accountable.

6. Fighting every attempt to regulate midwives.

7. Unconditional support for midwives under investigation or on trial when a baby dies. Creating a culture of animosity against mothers who speak out against dangerous midwives.

8. Not speaking out against dangerous midwives. There is an intrinsic code of silence in the midwifery community. Even when they think a midwife is at fault, they will stand in solidarity with her because they mistakenly believe that prosecuting dangerous killer midwives in some kind of medieval persecution. The concept of midwifery is more important than ethics, safety, integrity, or human beings.

9. Double standards:

Saying that birth is as safe as life gets, and then switching to the statement that birth is inherently risky when something goes wrong.

Blaming mothers for not doing "research" or failing to "trust birth" when a midwife fails to do her job.

Using scare tactics to keep women from going to the hospital or seeking obstetrical care, then blaming the mother for not transferring should something go wrong.

Telling women that "babies die in hospitals too" instead of taking responsibility for midwife neglect or error.

Wanting to be considered "professional" birth attendants, yet refusing to hold to consistent standards of education, scope of practice, oversight, regulation, and ethics.

Wanting to receive Medicaid and insurance reimbursements but refusing to hold liability insurance.

Saying they are not health care providers and do not practice medicine, yet demanding Medicaid reimbursement.

Claiming to support women, yet abandoning them if they speak out against the midwives who killed their children.

Sunday Evening Links

The Politics of Birth, Motherhood, and Sharing Our Stories:

Alexis Coxon Interview on Birth Stories on Demand Radio

Risk Them Out!

Home Birth Risky for High Risk Moms and Babies?

Skill for Skill

Dutch Midwives vs. American Midwives

 What's Up With All That Garlic?

Are Midwives Downplaying the Risk of Group B Strep?

Is a Movement Beginning?

Creating a Space for Natural Birth in the Hospital

Rest in Peace Little Roisin

Freebirth Baby Could Have Been Saved According to the Coroner

Remember Never to Time Travel While Pregnant!

Birth in the 17th Century






Home Birth More Cost Effective According to NHS.  

Is $600 bucks worth the "comparable risk?" 

How Do We Make Midwifery Safer?

In Michigan, as in many other states, the practice of midwifery is grossly unregulated.  Any woman who took a correspondence course or attended a few births can legally hang out a shingle and call herself a "midwife" and charge you to attend your birth. 

While there is a lot to admire about the Midwifery Model of Care, pregnancy, birth, postpartum, and neonatal care are too important to be left to amateurs, however well-meaning they might be.  There needs to be a balance between having a meaningful birth experience and the protecting the safety of babies and their mothers. 

So how do we do it?   This list, adapted from SaferMidwiferyMI.org gives us some guidelines.

• Informed Consent
• Midwifery clients should be fully educated and informed by the midwife of any real or potential risks involved in prenatal care, labor and delivery, neonatal care, and postpartum care.  Informed consent should be balanced and unbiased. 

• Consistent Standards for Education and Training
• All practicing midwives should have training from accredited midwifery studies programs that requires on site classroom participation, lengthy clinical practice, and supervised training by certified midwifery educators. 

•  Consistent Scope of Practice
• Midwives should follow clearly defined rules, regulations, and boundaries in their clinical practice. Only fully qualified midwives with substantial and appropriate training, knowledge, and experience may practice in the field of midwifery.  (Adapted from Federation of State Medical Boards 2005, p 19)

• Licensing Requirements for All Midwives
• Only those who have completed an accredited midwifery education and training program, passed a lengthy certifying exam overseen by a state medical board, and meet other licensing criteria should be allowed to use the term "midwife" professionally. 

• Licensing Requirements for All Birth Centers
• Birth Centers should be licensed and regulated by the state.  There should be accountability and oversight of all birth centers. All providers at Birth Centers should be licensed. Birth Centers should be required to report outcomes.  Birth Centers should also be accredited by an appropriate agency.

• Safety Protocols for Out of Hospital Births
• Midwives should only attend OOHB of mothers who meet the strict definition of a low risk pregnancy and birth.  
  

• Safety Protocols for Transfer of Care
• Midwives should arrange and encourage the transfer of care to an OB/GYN of all mothers who meet the criteria and definition of moderate to high risk pregnancy or birth at any time during the midwife-client relationship.  All and any real, perceived, or apparent emergency situations during birth should be reported immediately to 911 so that an appropriate and safe transfer of  care to a medical facility can be arranged.

• Required Reporting of Outcomes
• Midwives should be required to report all positive and adverse care outcomes to an appropriate state reporting agency that is available to the public.

• Liability Insurance for All Midwives
• All midwives should be required to carry liability coverage in order to be licensed and practice midwifery. 

• Accountability 
• Midwives should be held accountable for adverse outcomes by an appropriate and state regulated process which protects the rights and dignity of all parties involved, including the midwife and the clients involved.  Midwives found to be grossly negligent or in great error that resulted in the injury or death of a client or infant should lose their licenses to practice midwifery.

• Oversight
• The practice of midwifery should have oversight provided by a state board consisting of physicians, registered nurses, certified nurse midwives, licensed midwives, and citizens.  The state midwifery board should oversee the implementation of educational standards and requirements, accredited midwifery education programs, licensing, liability insurance, safety protocols for out of hospital birth and transfer of care, accountability and oversight, and mandatory practice reporting, as well as the implementation of a publicly available database of outcomes and disciplinary actions. (Adapted from Safer Midwifery for Michigan blogpost)

Deconstructing Informed Consent

The Midwives Model of Care states that part of the job of the midwife is to provide "individualized education" and "counseling" to expectant mothers.  According to the North American Registry of Midwives (NARM), the "cornerstone" of midwifery care is informed consent.

The term informed consent means that a healthcare provider must inform his/her patient or client about every possible benefit and risk involved in any type of  medical procedure or kind of treatment; the patient/client must also be informed of alternative courses of treatment. The healthcare provider must get the patient/client's signature agreeing to the treatment plan in writing.

Most people want to know what will happen to them if they have or decide against a form of treatment.  Everyone should have the right to make informed decisions about their health care.  But what do we mean when we say "informed?"

To be informed means to know all the available and relevant information. 

As an example of a informed consent document, NARM linked to the Informed Disclosure for Midwifery Care and Home Birth by Mountain View Midwifery in Virginia.  Here are some highlights:

"As licensed midwives we provide complete care for normal pregnancy, labor, home birth, and the postpartum period."

• Note the word normal. That means a healthy routine pregnancy and an uncomplicated delivery.  If you have diabetes, gestational diabetes, pregnancy induced hypertension, pre-eclampsia, a history of preterm labor, placenta previa, twins, or other high risk conditions then you are not a good candidate for home birth. 
• A good midwife should not take on clients who are high risk.  The term used is "risking out."  If you are not a candidate for a homebirth, she should refer you to an obstetrician.   
• If a midwife tells you that serious complications are just "variations of normal" and that the medical establishment just wants to "scare" you and take away "your birth experience," be very wary of continuing as her client.  She may be more interested in proving the popular midwifery saying that "birth as safe as life gets" than in your individual pregnancy and delivery.  A good midwife puts the health and safety of the mom and baby first.

"The main disadvantage of home birth is the limited or delayed
availability of emergency equipment and procedures."

•  It is important to be aware of the limitations of lay midwifery.  A Direct Entry Midwife or a Certified Professional Midwife is educated about normal pregnancy and birth.  The CPM credential does not require any hands on emergency birth experience prior to certification.  Your emergency might be your midwife's first one.

• You should have a frank discussion with your midwife about her qualifications and experience handling emergency situations.  Find out what equipment she is allowed to carry by state law.  Make sure she provides you with up to date documentation that she is certified in neonatal resuscitation and adult CPR.  Have an emergency transfer plan in place.  If she gives the name of a back up OB or hospital she works with, contact them for verification.

• Regardless of previous experience or inexperience with emergencies, your midwife cannot provide you with this level of care.

"Most obstetrical complications are not emergencies and many are predictable beforehand. Complications are best minimized with a healthy mother who maintains good nutrition and receives skilled screening and consistent prenatal care. True emergencies are rare and usually allow for sufficient time to get to a hospital, but there are no guarantees."

• Eating right and getting good prenatal care is essential.  Every doctor and midwife knows this is the key to minimizing potential risks. But skilled providers know that some birth complications cannot be prevented and they do not try to minimize their risks by calling them "rare" or saying they "aren't true emergencies." 

•  How close to you live to the hospital? Do you have "sufficient time" to get there?  How long does it take to drive there under normal conditions?  Rush hour?  During a rainstorm?  A snowstorm?  What about during a flood?  Will your spouse or midwife be driving you?  Can you walk to the car?  Are you even conscious? Will you need an ambulance?  How long does it take to call an ambulance, be picked up, and transported to the hospital? 

" Under both our license and certification we are required to establish practice guidelines, which serve as an outline for the scope of our practice. Our practice guidelines document is available to all of our clients upon request."

• Supposedly, this is an informed consent document.  So, why do clients have to request the practice guidelines?  If your midwife doesn't automatically share her practice guidelines in writing, then you should not sign an informed consent document until you have read them.  

 If midwives want their clients to be educated and informed, then clients need to be aware of the risks and potential complications.  They need to know what will happen if the unthinkable occurs. They need to know exactly what a midwife can and cannot do when there is a complication.  Sweeping risks away with the word "rare" and telling women that you can easily transfer "to the hospital" in an emergency is a disservice. 

How Rare are the Risks Anyhow?

The majority of pregnancies in the United States are complication free and the majority of births go well. So yours is likely to progress without a problem.  Kind of reassuring to hear, right?  Midwives tell this to their clients all the time.  The information is passed from mother to mother, friend to friend, sister to sister. 

"Birth is as safe as life gets." 

"Birth is a normal event."  

But what if....

You develop gestational diabetes?   It happens in 2-10% of all American pregnancies

You give birth prematurely?  12% of U.S. births are premature.

You develop pre-eclampsia?  5 to 8% of pregnancies worldwide develop pre-eclampsia.

You have a postpartum hemorrhage?  This happens in 18% of births; 3% of these are severe PPH.

You have a placental abruption?  This happens in 1% or less of  pregnancies.

You have a cord prolapse?  This occurs in less than 1% of all deliveries.

Sure these sound rare.  But think about what the word percent means.  It means per 100.

In other words:

1 out of 100-120 women have a placental abruption.  

12 out 100 babies will be born premature.

5-8 women out of 100 will develop pre-eclampsia during their pregnancy


18 out of 100 women will have a post partum hemmorhage during delivery.

Think about how many other women you know and see.  You have friends from high school, college, work, birthing classes, mommy groups, and the coffeehouse.  You know women on Facebook.  You see other moms dropping off their kids at school.  You pass by them in the diaper aisle at Target. 

 Approximately 11000 babies are born each day in the United States.

In one week, 77,000 babies are being born.

The university hospital in my college town community sees 4000 births a year.  The county population is around 345,000. 

Think about all the pregnant women running around the United States as we speak.  Hundreds of thousands. 
One hundred is not a lot in this modern world.  Chances are you talk to, walk by, and look at women everyday who have had some of these "rare" complications with pregnancy and delivery. Chances are you know one. Or more.
Does 1% still sound rare?