Moving...

The halcyon student days of mamamidwifemadness are now over. Now the real work begins.
I have moved to my new place at Homebirth Midwife.
Won't you come visit?

Update from Leafy Corner (and beyond)

So yes, months and months have gone by it seems and I have been unable to drag words out of myself sufficient to deposit them here...

• I have instead made much milk and grown a fat, lovely baby. He has two shiny, sharp new bottom teeth, much stronger opinions about things, and threatens to crawl.
  
• Attended an extra 6 births pursuant to stupid school requirement, took baby with. He lolled about as mother after mother pushed their babies into the world. Invariably he watched as if to find out what 'kind' of baby it was, then sighed deeply and promptly slept through the busy-ness of postpartum, newborn exam and cleanup. Without exception those births were lovely.
• Officially graduated from SMS (for real, this time, even have the transcripts and diploma now)
• Studied, traveled to California to sit the NARM exam, before attending the 2009 MANA conference where I finally got to meet Ina May. Briefly contemplated racing around snapping pictures to make a "Midwife All-Stars" trading card pack... Lots of cool people there, Ina May of course, but also Anne Frye, Saraswathi Vedam, Carol Leonard among others. MANAmania is indeed, just that. Much singing, and dancing, and telling of stories. I thoroughly enjoyed and was moved to tears hearing from Florida midwife Jennie Joseph. Want to eliminate racial disparity in preterm birth and associated morbidity/mortality? Check her method out. It's fantastically simple, and yet our mainstream maternity care system seems to be incapable of replicating it. Also caught up again with lovely Sherry of the Labor Payne Epistles.
• The MANA/ACNM Bridge Club was an epiphany. Many hurt CNM's and CM's (not to mention the CPM's) who had a LOT to say to the ACNM's reps who seemed to show up to stand in the fire. The ACNM is facing real challenges with nurse-midwives losing their jobs all over, their fickle physician allies are rumored to be training PA's to do births to "solve the midwife problem", while the MAMA campaign is forging ahead, making some pretty significant strides in furthering the CPM credential federally. Homebirth numbers nationally are still small, but homebirth is usually the domain of the CPM, with fewer and fewer nurse midwives practicing at home. My feeling is still that we must be midwives together, and if not, then the ACNM needs to step aside and get out of the way. Homebirth and CPM's will eventually overcome, and the option will inevitably be preserved. Midwives are perhaps the most stubborn people in the world.
  
• Passed the NARM (can call myself CPM now!!)
• Reaquainted myself with my family who had been without me (for all intents and purposes) for about 18 months
• Wrote and built phase one of my practice website (Well. I tortured Husband until he did that)
• Much practice start-up planning, negotiations and discussions with collaborating midwife.
• On a family level we've implemented brutally ascetic new financial regime in preparation for evil student loans coming due in January. It's not been terrible.
  

The rains and chilliness have come again to leafy corner. The fire is invariably in the grate. The pace of my life has diminished measurably aided in part by the hefty doses of oxytocin flowing as freely as the milk. I am discovering, as my train of thought is oft derailed, that milk coma is a shared motherbaby phenomenon.

I have between 3 and 6 births a month on the books for the next 6 to 8 months or so. Most of these as a birth assistant, but some will inevitably see me on first call and assuming the mantle of primary midwife for real. I'm really enjoying watching the growth of the new student in the practice as she gains confidence and skill. It's not my turn to teach, as I have so much yet to learn, but I am really looking forward to it when the time comes.

I continue working towards a series of meetings with our local hospitals with the mission of improving home-hospital transports. At the brilliant suggestion of a super cool OB from Canada who is using this technique in his mission to enhance communications betwixt midwife and physician in Canada, I'm contemplating pursuing some training in Compassionate Listening. Figure it can't hurt, might help.

Not about homebirth, except when it is.

Originally posted elsewhere April '09. Thought it was worth putting up here too.

Of late, I've heard several senior midwives in my community voice concern that media attention is being focused too closely on home birth, and too little on midwifery care, which indeed is probably the key factor to all the excellent outcomes which midwifery clients enjoy. I've sat and mulled over this for a couple of weeks now, about what place homebirth should take in campaigns to further access to midwifery care. Is it ALL about midwifery care? SHOULD we shift the focus away from homebirth?

It's true, we DO need more midwives providing midwifery care to improve this horribly broken system women are fed into routinely, and fed out of with more than their fair share of iatrogenic morbidity (unnecessary cesareans anyone?). But we also need to take a deep breath and look closely at where we're at and what it is we are really asking for.

When compared with the hundreds of thousands of babies born in hospitals annually in the US, homebirthed babies are rare and precious creatures. Homebirth is still considered 'fringe' in many quarters in this country, though homebirth advocates (usually those who've actually experienced the difference!) are vocal and impassioned. I think it's easier for all of us to focus on the stunning, life-altering shift of a baby born into a mother's or father's trembling hands than it is to dissect the much less awe-inspiring (and certainly less sexy, media-wise) impact of good, thorough, woman-centered care during the childbearing year.

Direct entry midwives/Licensed Midwives/Certified Professional Midwives provide midwifery care in out of hospital settings. We achieve excellent outcomes for both mothers and babies at HOME and in FREESTANDING BIRTH CENTERS. We do this in deceptively simple but extraordinarily cost effective ways. We spend TIME with our clients. Hospital OB practices are occasionally (dare we hope increasingly?) taking a leaf out of the midwives' playbook, making that same commitment and guess what? They're lowering their CS rates (and I'd bet their client satisfaction rates are climbing too). If it were possible for physicians broadly to set aside the focus on pathology of pregnancy and birth, and apply the very basic tenets of midwifery, I think we'd see a shift away from the 32% cesarean rates, probably see a shift away from the low birth weight and premature birth rates, increases in breastfeeding rates and associated life-long health benefits to both mother and babe, to say nothing of the profound impact a shift like that could have on women's lived experience of their care, and entry to motherhood. We need only look to physicians like Marsen Wagner, Sarah Buckley, Michel Odent and hundreds of other less well-known physicians worldwide who we laud as being revolutionary. They might be within their circles, but they're just talking about midwifery care, are they not?!

As I write this, independent (homebirth) midwifery in Australia is being sold down the river by none other than the Australian College of Midwives. In a schism which I find oddly reminiscent of the divisions which keep midwives in the US divided and effectively conquered: So called "independent" homebirth midwives will be de-registered and find themselves practicing illegally if they practice without professional indemnity (malpractice) insurance. Midwives working within hospital birthing units however will receive limited prescriptive authority, increased autonomy and the indemnity insurance. The College appears to be effectively trading independent midwives livelihoods, not to mention Australian women's birthing choices so that they can increase their hospital purchase. Their logic I'm sure is that this will increase women's access to midwifery care. Perhaps it will, but at what cost? My bet is that it will marginalize further those women who seek to birth at home, further limit access to VBAC (a whole other note), and force midwives to practice illegally - to no-ones benefit whatsoever.

Last year the American Medical Association at its annual meeting it adopted a policy written by the American College of Obstetricians and Gynecologists against "home deliveries" and in support of legislation "that helps ensure safe deliveries and healthy babies by acknowledging that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital" or accredited birth center. When powerful physician trade union interests are threatened sufficiently that they call for legislation to restrict women's choices in birth, or intervene successfully to lobby to have pro-midwife legislation voted down in state houses (as happened this week in Michigan), midwives need to recognize that this is a basic threat to our livelihoods, to women's choices in maternity care, and her right to birth wherever she chooses. In this way it IS about homebirth.

And so, if it's the impassioned, satisfied home birth clients and the "ooh" factor of homebirth which keeps midwifery care at the forefront of the momentum to reform our broken mainstream system, then so be it. I've become a homebirth midwife because I didn't want to be a CNM, or an OB. I'm not ashamed or reluctant to talk about the fact that I will care for women inside their homes, and handle transports to higher level care when and if women need it. I feel that the midwifery care I provide to healthy, low risk women is far superior to medical or high-volume CNM midwifery care women and their babies experience in hospitals. Every opportunity I get to talk about homebirth is a springboard to larger, more important discussions about thorough informed consent, the wider benefits of midwifery care, about how mothers and babies DESERVE better than they're getting.

I personally look forward to a day when I can attend my clients in the birth site of their choice: home, birth center or hospital, but that's a ways off for most LM/CPM's (though it IS happening people!!). I would note also though, that I wouldn't ever give up homebirth practice. CPM/LM's are, I think at heart, home birth midwives. Without birth at home as a legitimate, well-championed choice, we all lose. Not least of all the midwives.

Direct entry midwifery in the United States IS proudly, unashamedly, wonderfully ABOUT homebirth. I would suggest we forget that at our peril.

Thinking about ACOG's survey

So, the more I think about the way the survey was worded, the more I realize that they're framing the discussion in terms of "we're gonna get sued for care we weren't a part of until things went bad." I'm not sure that that's happening, midwifery clients are less likely to sue because of the relationships they build with their midwives, but perhaps after a bad outcome after a transport they may be more inclined to lay blame at the feet of the hospital staff? Most of the OB related law suits I've heard of have resulted in everyone in the vicinity being named, physicians, nurses, midwives, everyone. So ACOG is perhaps misplacing their concern. I confess to getting a little irritated at their constant fretting over potential litigation. Perhaps if they spent more time with their clients and addressing some of the systemic flaws in a system which drives a significant chunk of homebirthing women our way fewer suits would follow. But I digress...

ACOG seems increasingly threatened by the groundswell of support for midwifery care, and appear clueless about just how tech-savvy the movement has become. I've been chuckling a little imagining their surprise when they realized that so many midwives and homebirth clients hijacked their silly survey!

Another thought which I have percolating is that the county call physicians who are called in to 'manage' transports (which are invariably for non-urgent scenarios: pain meds, needed augmentation and the like) can and I'm sure DO face exactly the same set of dramatic rare complications coming through the doors (things like cord prolapse, abruption and the like) from their own patients, and women who walk in off the street as well as the very occasional unlucky homebirth client. This being the case I'm inclined to ask: what is the difference?? I'd also point out that some of the other issues postpartum hemorrhage etc. are perhaps more likely to occur iatrogenically inside hospitals under their own protocols due to the widespread, routine application of pitocin for just about every laboring woman. What we use as a first-line treatment for bleeding doesn't work as well in a uterus which has been soaking in it for hours.

And then, amongst all of this is the feeling that I have, that has been expressed much more eloquently in the wonderful huge Dutch study and several good UK studies, that none of this has to be this way. If Docs would work with midwives (and yes, some do!) to provide excellent care throughout the course, we'd probably be happier transporting in. The clients would feel safer doing so, and if we midwives actually had a cats hope in hell of developing a working, consulting relationship with a physician willing to take transports, the docs would know and trust that the midwives were transporting prudently, in a timely fashion (which most midwives DO!). There's ample evidence that this OPTIMIZES outcomes.

I just wish we could all get to the table in some meaningful way because there is SO much bullshit flying around!!

My goal for my practice is to make sure that all of the OB's and family practice docs in my community know I'm here, know that I'll do my level best to ensure that my clients are thoroughly taken care of, that I'll consult and transport in a timely fashion and use my state midwifery organizations Guidelines for Transport. I want them to come to understand that while we don't have to always agree with each other's ways of doing things, we do have to agree that professional respect is in order and, when we transport into the hospital into the care of whichever county doc is on call, we're on the same team. It's a phrase used too often used, but midwives DO care deeply about healthy mom, healthy babe, as much as I know doc's do. The difference may be that midwives value the birth process more, have had the benefit of a lengthy prenatal course to understand thoroughly a woman's hopes and fears, and understand that in many ways there's more to healthy than two heartbeats. I can be completely sure though that there isn't a midwife or mother who would willfully compromise the health of a client or a baby for a vaginal birth at all costs. It is antithetical to midwifery care.

I've had some phenomenal transports to a local hospital in my area in which nursing staff and docs have acknowledged in a very heartfelt way: "We understand that you didn't want to be here, but we'll do everything we can to help you achieve as many of your birth wishes as we can." These have been the transports which give me hope that LM's can work beautifully alongside physicians. I've also had other, less-than-stellar experiences which were notable not for overtly poor care of the client, but for outright disrespect and awful treatment of the midwife. Even when the transport was handled superbly from the moment trouble was discovered, to the EMS call, to the hospital doors. From there things went downhill. There's no excuse for this. None.

What ACOG seems not to understand is that midwives are not going anywhere. Women are going to chose to birth out of hospital in greater numbers as they realize that they have a much better shot at continuous, thorough, woman-centered care with midwives in OOH practices. Midwives have always been here, with woman, and we will always be. We do this knowing that sometimes we need the docs and all the hospital bells and whistles, and we transfer knowing that it's often a crap-shoot as to what sort of reception we get. For midwives (and their clients) who strive for consistency and excellent care, being tarred with the "crazy homebirthing folk" brush, and the occasional glaring ignorance of hospital staff ("Oh, you've brought prenatal care records with you??"), it's anxiety provoking to say the least.

As a newbie midwife I know that it will take me a long time to build physician trust in my clinical decision making. Hell, I understand that it will serve me well to practice VERY conservatively until I get my feet well under me as an OOH midwife. The piece I can work on though is the getting to know you bit. I can offer to come talk to the EMS crews, and the OB nursing staff. I can show them our transport forms and my practice guidelines. I can be very open and available with the physicians in my community, and I will be ready to call and ask questions when I have them. I'm a part of their community, and some of my clients will inevitably wind up being their patients. Just as it's my responsibility to care for my clients to the best of my abilities, according to the established standards in my community, it's also their responsibility to care for patients who need their skills and expertise, no matter where they come from: another doc, a midwife or just walking off the street.

Don't we share the common goal of caring for women and their babies throughout their childbearing cycle? Sure we do things differently sometimes, and yes, I've only attended a fraction of my births training in a hospital. With that said I can guarantee that even as a brand, spankin' new, just-outta-school midwife I've managed more births at home (and the occasional deviation from normal) than any single physician in a three county area. It ain't a pissing contest, but we need to move past the whispers of terrible homebirth catastrophe stories (which are invariably patently false) and back turning, and refusal to have anything to do with each other and get on the same page (or as close to it as we possibly can). Women, their babies and our shared community health-care resources depend on it.

Still alive and ACOG's latest folly.

One birth away from completing the contested requirement for school, then miscellaneous paperwork, a couple of remaining visits on a continuity of care and then, folks, I can divorce myself from my alma mater. Our parting is not 100% amicable, but whatever. I'm a midwife and that was the goal.

Am scheduled to sit the NARM in October at MANA (anyone want to catch up?!) and enjoy the goodness and recharging that comes with sitting in a room of women who get it, and the swirl of white hot politics which surround the profession at the moment. Midwifery and politics is kinda like margarita and roasted marrow bones to me. Favorite things and all that.

Some interesting things have been floating by of late which I'm hoping bloggers with more time on their hands than I do can take up and beat to death. Most notably this evening I've become aware of a mindblowing ACOG survey which I suspect will dissappear shortly (it's sooo ridiculous I have to hope they'll see how idiotic it is and pull it). In the face of yet more recent compelling international research supporting the safety of midwifery care at home, and the powerful momentum behind the MAMA campaign, the Big Push ACOG is hunting desperately for anonymous anecdotes of poor transport outcomes.

"The American College of Obstetricians and Gynecologists is concerned that recent increases in elective home delivery will result in an increased complication and morbidity rate. Recent reports to the office indicate our members are being called in to handle these emergencies and in some instances have been named in legal proceedings. To attempt to determine the extent of the problem, a registry of these cases will be maintained at ACOG on a year-by-year basis."

I'll restrain my comments to simply observing that, for an organization who is so fond of brandishing the "gold standard" of the randomized controlled trial, negating the fact that birth cannot be randomized, and tarring the best studies available with the judgment that they are of "poor methodological quality": Pot calling kettle black, much?

Independent midwifery in Australia is under pretty dire threat. See Lisa's blog and the many fine videos on the subject which are all over YouTube at the moment. If you're in Canberra go to the rally on Sept 7. Numbers will count. There is a way you can attend virtually Homebirth Australia will have more info if you're so inclined.

Have enjoyed these last few weeks on call. Four lovely births, three babies caught by their mothers (dad's assisting) in the water. Three births which Alec attended with me, watching quietly in the corner, or dozing. He's a doll.

I'm starting to get organized business-wise, I have a phase 1 website up, and am beginning to talk to a few families who have babies due early next year including a couple who I worked with as a student in a prior pregnancy. I'm penning letters of introduction to the local docs, and will shortly begin introducing myself formally to the EMS crews in my neighborhood and the L&D nursing staff at the local hospitals. This piece of the puzzle is important to me and I'm really, really enjoying it. While I don't expect a mad rush of "Wonderful, there's a new homebirth midwife about!" sentiment, I'll be happy knowing that they know I'm here, and that I care about our working relationships. The rest will have to come over time. I am nothing if not persistent.

This next phase promises to be a hard slog, but I'm grateful and happy to be finally beginning.

Oh yeah, and here's my waterbaby, who keeps me away from the computer so much.

Take THAT, ACOG!

Backassward

Ok, let me preface this with the fact that I'm only slightly post-coffee, and so my morning hair-trigger persists a little. But HOLY shit, what is it about the reactions to the Pit to Distress discussions?? Mercifully most of the reactions have been ones of disgust and anger (where I think they should be), but increasingly I'm seeing it spun into two camps: the "this wouldn't be happening if women didn't all ask to be induced so often because they're miserable, or their inlaws are coming, or doc is going on vacation" or the nursing camp which is focussing on the nurses responsibility to decline, or argue unsafe physician orders. It's not even about whether or not the words "pit to distress" or "pit to D or D", or whatever else are written into the chart or are accepted as a reasonable option in any hospital. While the nursing ramifications of these types of orders are very reasonable discussions to be having, NONE of these angles addresses the issue at hand!

Regardless of whether or not a woman is so rediculously miserable with being pregnant, or whether a nurse can use her hospitals protocols as back up to refuse to administer what she feels is an unsafe dose of medication we're talking about a system in which physicians are allowed to practice in a manner which is DANGEROUS and LIFE THREATENING. We MUST NOT blame women for presenting for an induction when they have (usually) been given what they -and probably their physicians - truly believe to be good clinical reasons. We MUST NOT blame the nursing staff for having to act as the safeguards for their patients (or not being able to, as the case may be). We HAVE to call the physicians (ACOG?!) on this particularly vile mismanagement and the medical school programs who teach their students that labors can be 'managed' this way. Where's the accountability?!!

I don't give a rats ass (sorry again, it's the coffee) if some quarters believe that this isn't common and therefore not worth getting worked up about. In the last few days I've heard first hand report after first hand report, in my state (where incidentally the ACOG chair - who is very pro-midwife and homebirth - when asked about this was shocked and appalled too), in other states. When the words "pit to distress" appear in textbooks the case can be fairly made that this is happening too frequently. Honestly I believe that even once would be too many. If you're uncertain if a mom/baby needs a cesarean, then to my mind you have two options: 1. You make the decision that the dyad needs a cesarean (hopefully for a sound clinical indication) or 2. You WAIT and WATCH for a true indication that takes them to the OR. Throwing high dose pit into the equation to accelerate this call is simply reckless and also, I think, cowardly. Asking nursing staff to participate in that process is beyond cowardly. I've stood up and applauded for the nurses who have made it clear to their physicians that "they want the pit turned up, they can do it themselves". The nurses shouldn't have to fight to 'protect' their patients.

As ever rising cesarean section rates are debated in this country I think that we have to very closely examine the reasons which are so commonly brandished by the physician camp: "you don't get sued for doing a c/s, you get sued for not doing one", "The childbearing demographic has changed" (AKA, too old, to fat, too short, too young etc. etc.), and address more closely the MANAGEMENT of pregnancy and labor in this country. Midwives are working largely with the same demographic, and yet through attentive, comprehensive, holistic prenatal care, excellent childbirth education, one on one labor support, and yes, no routine pharmaceutical augmentation of labor, we manage to facilitate vaginal births for many, many more women just as safely. All that, AND midwives are many times less likely to be sued by clients, even after bad outcomes - even in states where professional indemnity insurance is available to midwives. Why? Probably because midwives take the time and work hard to establish solid, trusting relationships with their patients - something which (respectfully) is tricky to do when you only see your physician for short minutes at a time and who (usually) step into the room as your baby crowns. So the "you don't get sued for doing a c/s" thing rings hollow. All too often mother/physician relationships are based on blind faith that your doc has your best interests at heart. Clearly though, as we discuss "pit to distress" that faith is terribly misplaced. That this is happening AT ALL, ANYWHERE, is TOO MUCH.

What we need to figure out is what we have to do to stop it and we have to stop blaming the women for what happens to them when they walk into a hospital.

File this under stupid, dangerous and malpractice.

I'm finding I have little time to write as fully as I would like about a blog post I stumbled across the other day which, for the first time in a while got me newly, thoroughly outraged. Fortunately the universe has good people like the Jills from Keyboard Revolutionary and Unnecessarean to do it for us.

I've spent a little time researching this "Pit to Distress" and have found, justly, that L&D nurses don't like it a helluva lot. I wouldn't either if I was the one being told to administer the doses when the only desired consequence (that I can see) is to stress a baby and clear the bed, probably due to a thoroughly iatrogenic 'emergency' cesarean for fetal distress. This also handily would allow OB residents to rack up another surgery before the end of a shift. I fervently hoped that this protocol is NEVER used on VBAC women. Sadly, many of the tales on nursing message boards discussing "pit to distress" were of VBAC mamas whose labors were augmented this way simply to ensure that their TOLAC (trials of labor after cesarean) failed, and quickly. What's the bet the women had NO idea that their labors were being forced to a frightening conclusion.

I have yet to figure out one single good, safe, clinical indication for this use of pitocin. Instead all I can come up with are the risks. The tale of woe outlined in N is for Nurse's post is notable for the eggregious malpractice on the part of the physician involved. Thank GOD the nurse quietly refused to augment a mother who may have been abrupting, was already (from the sound of it) in tachysystole, and had a babe with minimal variability (hallmarks of a babe already stressed and with low reserves). I just don't understand what it was that the Resident who made the order was thinking. ESPECIALLY given that it sounds as though the anesthesiology team was otherwise occupied. I really feel for (and am stupidly grateful to) the nurses who keep their patients safe when stupid stuff like this is in play. It must be tough going up against physicians who want to do dangerous things and want them, the nurses to basically run the show in their absense.

In the meantime counties in sunny Florida are enjoying (??) cesarean section rates of more than 50%. an outrage which defies logic and any rational explanation. This is not good practice, it's completely indefensible, I'd go so far as to posit that it's not even medicine. If I were a taxpayer in Florida I'd be calling my legislators daily and reaming them for allowing my public health and medicaid tax dollars to be spent this way. There is NO excuse for this. Physicians and hospitals in Florida should be ashamed of themselves.

Some other good media from the American Prospect. Turns out some smart economist out of Kentucky crunched the numbers and found that the US healthcare system could save $9 Billion a year if only 10% of American women enjoyed midwifery care and birth out of hospital. The majority of these savings would be made simply by reducing the cesarean section rates and their attendant complication rates. Bottom line: if you are planning a physician attended hospital birth your risk of a cesarean sits about 30% (or considerably more depending on your hospital, physician and geographic locale). Now, your average Certified Professional Midwife attending home births generally manage cesarean section rates of less than 10%. More and more legislators are asking "Huh. So what is it that you midwives do differently?"

Today all I want to do is point to the post which got me onto this topic and say " Well, among other things, that. We don't do that. Ever." Because not only is "pit to distress" unsafe, I think the case could be made that it also amounts to assault and battery on the mother involved, and reckless endangerment of the fetus.