California College of Midwives
3889 Middlefield Road
Palo Alto, CA 94303 // 650/328-8491
www.collegeofmidwives.org
Medical Board of California
Division of Licensing (DOL)
1426 Howe Ave
Sacramento, CA
January 29, 2004
Dear DOL Members,
At each Board meeting or midwifery-related regulatory
hearing the question inevitably arises as to whether community-based midwifery
is “safe” as defined by the scientific literature. Board members
repeatedly state that they either are unfamiliar with the literature or they
question whether or not published studies even exist. I assure you that such
documentation does exist and that to become familiar with this scientific
literature is to redefine the politics of this controversy. The official
debate will no long be how to protect the ‘consumer’ by stopping licensed
midwives from providing care and but rather how to protect the consumer by
helping them access the care of LMs and helping LMs better access medical
services in a timely and appropriate manner.
The overwhelming
scientific basis for physiological management of
normal pregnancy and birth, as published in peer reviewed journals and other
types of public records, makes a stack that is wide, tall and impressive. I
personally have over 40 three-ring binders which contain historical sources
documenting organized medicine’s historical campaign against midwifery, and
peer-reviewed studies and science-based reports that validate the safety of
physiological principles and emphasize the countervailing risks of
medicalizing healthy women. One particularly insightful study on relative
safety of place of birth wisely noted that:
Although home and hospital offer
different risks and benefits, neither has standard care characteristics. In
fact, the range from safe to unsafe practices may be wider within each
location that it is between them. Addressing what constitutes safe
practice at home may be a more pivotal concern than attempting to quantify the
theoretical differences attributed to place of birth. (Perinatal death associated with planned home
birth in Australia: a population based study, BMJ
1998:317:384-388 (8 August)
[emphasis added]
The
overwhelming consensus of the published research is that community-based maternity care by
professionally trained midwives, in conjunction with access to obstetrical
services for complications, is statistically equally to that of hospital care
under obstetrical management. Physiological management by midwives in
non-medical settings is actually protective of both mothers and babies,
reducing the operative rate, along with its associated complications, from approximately
37% to approximately 5% with a virtually identical, or even slightly improved
perinatal mortality rate. (MCA "Listening to Mothers",
2002)
In
an effort to address concerns of safety as voiced by Board members and staff, I have
provided about a hundred pound of these studies on a one-by-one basis over the
last 11 years. This included many letters to individual Board members in which
I quoted studies and included abstracts and excerpts of studies and reports
that were highlighted with a bright yellow marker to make scanning easier.
However,
there
has been no mechanism for establishing an institutional memory
on this important issue by transferring this information to newly appointed
Board members or staff .
In response to this
problem, I have now compiled an extensive sampling of the research on the
efficacy of physiological management and domiciliary care as provided by CNMs
and LMs.
Out of approximately a hundred research papers on the
relative safety of different providers and/or birth settings, I have
photocopied 25 of the major studies. In addition I have reproduced perinatal
statistics, abstracts of other research, published editorials and excerpts of
pertinent material, including sections from the standard of care document and
practice guidelines for community-based midwifery. I have also included a
report on the future of midwifery from the Pew Charitable Trust, a survey from
the California Senate Office of Research on LM practice and another survey
commissioned by the Maternity Center Association entitled Listening To
Mothers. This sampling represents the most significant research
published in the last three decades on the physiological management of normal
childbearing and community-based maternity services. This is a total of 500
pages, divided the material into
two 3-ring notebooks for easier use.
I’d like to specifically note three of these studies.
The first is a “Delphi study” (notebook
2, section 6) called A Model of
Exemplary Midwifery Practice: Results of a Delphi Study (Jour
Midwifery & Woman’s Health, vol 45, Jan/Feb 2000) by a PhD nurse-midwife who is the director of the nurse-midwifery program at the University
of Rhode Island. I was
a contributor to this study and was quoted on page twelve as the originator of the concept
and expression The Critical Difference: The Art of Doing 'Nothing'
Well. It was my observation that the "work" of a midwife is to
provide physiological management and emotionally supportive care as an "educated observer with emergency response capacity" while simultaneously
refraining from interrupting or disturbing the spontaneous process of normal
labor. I characterized this as mastery in the 'art of doing 'nothing' -- in
contrast to the obligatory drive or 'doing-ness' of intervenventional
obstetrics. Ultimately, the "The Art of Doing 'Nothing'
Well" became the title for
Dr. Kennedy’s poster presentation.
The second study of note is the Survey Results on
the Practice of Licensed Midwifery in California (March 2001) by the
Senate Office of Research (notebook
1, section 3). Co-incidentally, I also helped the staff in the Senate
Office of Research to formulate survey questions to elicit information on the
issues of safety and the availability of physician supervision. The survey
noted that medical consultation and transfer rates (6%) as well as emergency
and non-emergency hospitalizations (4%) for clients of licensed midwives are
both low. It also reported that only 3% of California LMs (total of 2)
indicated that they had a relationship with a physician that involved the
legally mandated supervision. This report also stated that “a number of
studies have shown that the outcomes of planned out-of-hospital births are
comparable to, or better than, those associated with hospital births”.
The third study that I want to call attention to is a
Ph.D. thesis done at Stanford University in 1999 entitled The Safety of
Alternative Approaches to Childbirth by Peter F Schlenzka, Ph.D. (notebook 2, section 7). Dr Schlenzka
accessed computerized records for two consecutive years
for all California birth certificates (a total of 1.2 millions births)
and separate hospital discharge records for mother and baby. This resulted in
a total of 3.6 million data points. His study is the most powerful (i.e.,
largest) and also the best triangulated (cross-checking of data by three
different sources of records for each birth) of any research comparing birth
setting and management style for relative safety of both mother and baby. Of
the 1.2 million births in the original cohort, Dr Schlenzka determined that
71% of them met the study criteria for home-based birth services (normal
pregnancy in a healthy woman, low to moderate risk labor). For this data, set
(which excluded lethal congenital anomalies), the mortality rate was 0.56 %
or 1/5th of the perinatal mortality rate (2.65 %) for the
29% of the population that was identified as high risk. He concluded the
following:
… We conclude that low-risk women who opt for a
natural childbirth approach [i.e., physiological management] in an out
–of-hospital setting will experience a slightly, though not statistically
significant, lower perinatal mortality than low-risk women who opt
for a hospital birth under the management of an obstetrician. [p.1]
Our data also suggest that even for the high
risk-levels of our study population the natural approach (including
transfers) produces the same perinatal mortality outcomes as the
obstetric approach. .... Our analyses of the California data for 1989 and
1990 do not support the claim by the obstetric profession that for
the large majority of low-risk women hospital birth is “safer” with
respect to perinatal mortality. [p.1]
…The already apparent disadvantages of the
obstetric approach are of such a large order of magnitude, that in any
clinical trial it would be considered unethical to continue with the
obstetric “treatment”. [p.
175].
emphasis added
I have a hard copy of the entire thesis (total 218 pages)
and also a 35 page synopsis, either of which I would loan to anyone
interested in reading Dr Schlenzka's research.
The two-notebook literature set provided to each DOL
Board member will permit easy access to scientific documentation on the
historical background, contemporary practice and standards of care for both
LMs and CNMs, as well as general safety and efficacy. I
have individual copies of these notebooks for each of the seven appointed seats
on DOL. As this is a very time-intensive and expensive proposition. I ask that each member retain his or her copy for the
foreseeable future. When individual members of the DOL completes their term
of office, I ask that the notebooks be returned to the MBC staff so that they
can be passed on to the next appointees. For those Board members who received a
DVD copy of the “Great Debate”, please add the DVD to the pocket on
the front or back covers.
I will also be forwarding this documentation to the AG's
Health Enforcement Task Force office and to the Office of Administrative Law (OAL).
I know that the MBC provides a 6 hour orientation on video tape to newly
appointed OAL judges on the theory behind laws relative to the authorized,
unauthorized and illegal practice of medicine, medical terminology and the
specialized vocabulary of anatomy, physiology and pharmacology. We request
that this process of orientation also apply to the discipline of midwifery and
believe this documentation to be a good beginning to this in-service education
process.
It has been 11 years since the passage of Licensed
Midwifery Practice Act of 1993 (LMPA) and a decade since the midwifery
implementation committee meetings were held by the MBC. As a participant in
all seven of those day-long meeting chaired by Dr Joas, I and other midwife
licentiates assumed that the science-based information on midwifery principles
and practice would trickle down naturally to the agency staff and Board
members. After a decade, I think we can pronounce that theory a failure. As a
result, direct measures seem necessary to assure that agents of the regulatory
Board for midwives and those in authority in the AGs office and the OAL are
mutually informed about matters that are crucial to their ability to make
informed decisions about the practice and regulation of licensed midwifery.
The
Official Role and Function of the Scientific Literature
Next to God and President
Bush, the seven members of the DOL have the first and last word on policies
regarding the practice of licensed midwifery in a state that represents the 5th
largest economy in the world. With the exception of the two public members of
the DOL, each member has a Ph.D. in medical science and is therefore an
“expert” schooled in assessing technical information relative to making medical
diagnosis and planning complex medical treatments or surgical operations.
As Ph.Ds, physicians are also particularly skilled in
reading and digesting the technical and statistical aspects of research
articles and scientific studies published in professional journals. The duties
of DOL members also include the weighty responsibilities of analyzing
documents relative to MBC licentiates accused of unprofessional conduct. These
sophisticated fact-processing abilities are also required to properly present
the activities of the Board to the public and other state agencies. Frankly, I
assume that the same level of intellectual inquiry and critical thinking
skills will be utilized when analyzing midwifery-related research and when
considering any form of testimony or other communication that bears on the
efficacy (or lack thereof) of the professional discipline of midwifery.
It may come as a surprise to some members of the Board
that persons in leadership roles within organized medicine are actually very well
aware of the safety of domiciliary midwifery, most especially when provided by
professionally trained midwives. If not, the medical association and its
predecessors would not have gone to such great lengths over the last 50 years
to keep the Office of Vital Records from accurately registering midwife
attended home births. If organized medicine really believed its own
negative account, its representatives would be hiring lawyers and going to court to force
midwives and state agencies to accurately record each and every midwife-attended
home birth, since doing so would establish its claim of medical
superiority and midwifery inferiority.
However, the inverse is actually true. In 1957
organized medicine lobbied to take the word ‘midwife’ out of the 1915
birth registration law. Since then the medical association has gone to great
lengths to prevent the accurate documentation of midwife-attended births, as it
would provide indisputable validation of the scientific literature – that
professionally attended labors and births in domiciliary settings have
outcomes equal (or superior) to those of hospital deliveries.
The historical and on-going campaign by organized
medicine to conceal the efficacy of midwifery care can only lead one to
conclude that the obstetrical profession is not nearly as interested in safety
of mothers and babies as it is in maintaining control over women’s
reproductive biology. This control is especially focused in unnecessarily
medicalizing normal birth in healthy women.
Healthy
families seek out home-based midwifery services not because
they are indifferent to the safety of their babies but because it offers
the only access to the safe and scientifically sound principles of
physiological management – non-interventive methods that facilitate
spontaneous labor and normal birth. Unfortunately, our tort laws currently
force doctors to provide interventionist care irrespective of the health
status or the stated desires of the mother. It should be noted that this
creates an asymmetrical burden of risk that falls unfairly on the
childbearing woman, in which the mother is exposed to the actual pain and
potential harm of medical and surgical interventions in order to reduce the
risk of lawsuits for the obstetrician. Many women feel that this is
totally unacceptable.
A ‘reality check’ in
regard to the actual dangers of normal childbirth for healthy women may be
useful. It is a serious misunderstanding to assume that normal biology is
itself dangerous. For healthy women who are enjoying a normal pregnancy with a
healthy baby (often confirmed thru ultrasound), the typical “risk” she
faces today is not normal labor but the routine use of uterine
stimulants to accelerate progress, narcotic drugs for pain and the use of
anesthesia so that surgical procedures or instruments can be used.
The litany of immediate
complications from the use of these interventions, such as hemorrhage and
infection, and downstream complications such as pelvic organ prolapse and
incontinence, are amply documented in the literature. According to Dr. Peter
Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics &
Gynecology at the Albert Einstein College of Medicine in NYC:
These
adverse side effects may be more the result of how current obstetrics manages
the second stage of labor. Use of
episiotomy and forceps has been demonstrated to be associated with
incontinence in numerous studies. Perhaps also vaginal delivery in the
dorsal lithotomy position [lying flat on the back] with encouragement from
birth attendants to shorten the second stage with the Valsalva maneuver
[prolonged breath-holding], as is commonly practiced in developed countries,
contributes significantly to the problem.
emphasis added
However, many who are
antagonistic to midwifery typify the choice of a ‘natural birth’ as
self-centered and hedonistic. Nothing could be further from the truth.
Choosing to abstain from pain medication and anesthesia in the middle of labor
or birth is very difficult -- a courageous thing to do. Women take this hard road
because they know that it is actually safer. At the same time, they are equally willing to be
medicalized or consent to surgical intervention should such things become
necessary for their baby’s safety. Hospital labor rooms are the only area of
life that I can think of in which just-saying-no to narcotics and other potent
drugs by a pregnant woman is interpreted as a callous disregard for the
well-being of her unborn baby.
The pain medication most
widely used in obstetrics today is fentanyl, a synthetic narcotic that is a
100 more powerful than morphine. It is administered as a pain shot and also is
the standard epidural anesthetic. Fentanyl was the drug used by the Russian
army in their ill-fated attempt to end the terrorist take-over of the Moscow
Opera. Unintentional overdose with an aerosol form of fentanyl resulted in the
accidental death of 130 of the freed hostages and permanent neurological
damage to many other victims.
The
other area that the obstetrical profession considers just-saying-no to be
irresponsible is continuous fetal surveillance via electronic fetal
monitoring. The obstetrical profession has long promoted the idea that
continuous EFM prevents birth complications and that it is irresponsible not
to use it. Since continuous electronic monitoring is not routinely employed in
a domiciliary setting, obstetricians insist that it is unacceptably dangerous
for a healthy woman to labor at home or freestanding birth centers. For the
last three decades representatives for American College of Obstetricians and
Gynecologists (ACOG) have used some version of this argument in the public
press, with the legislature and in testimony at MBC regulatory hearings to
advance their opposition to community-based midwifery, which they characterize as a dangerous and technologically-outdated form of care.
However,
no less an entity than ACOG has recently concluded that they were mistaken
about the ability of continuous electronic monitoring and liberal use of
cesarean section to reduce the rate of cerebral palsy and other neurological
disabilities. The failure of EFM and cesareans to prevent these neonatal
complications has recently been documented in
a July 2003 report by ACOG Task Force on Neonatal Encephalopathy & Cerebral
Palsy, which stated that:
Since the advent of fetal heart rate monitoring, there
has been no change in the incidence of cerebral palsy.
…. The majority of newborn brain injury does not
occur during labor and delivery. Instead, most instances of neonatal
encephalopathy and cerebral palsy are attributed to events that occur prior to
the onset of labor."
This
ACOG task force report had the endorsement and support of six major federal
agencies and professional organizations, including the Center for Disease
Control & Prevention (CDC), the March of Dimes and the obstetrical
professions in Australia, New Zealand and Canada. It is described as
the "most extensive peer-reviewed document on the subject published to
date."
An
August 15, 2002 report in Ob.Gyn.News stated that:
…performing cesarean section for abnormal fetal heart
rate pattern in an effort to prevent cerebral palsy is likely to cause as
least as many bad outcomes as it prevents."
.... A physician would have to perform 500
C-sections* for multiple late decelerations or reduced beat-to-beat
variability to prevent a single case of cerebral palsy. [** n.n.t. or
‘numbers needed to treat’] emphasis added
The
September 15, 2003 edition of Ob.Gyn.News stated that:
The increasing cesarean delivery rate that occurred in
conjunction with fetal monitoring has not been shown to be associated
with any reduction in the CP rate...
... Only 0.19% of all those in the study had a
non-reassuring fetal heart rate pattern.... If used for identifying CP risk, a
non-reassuring heart rate pattern would have had a 99.8% false positive
rate...."
emphasis added
Fortunately,
there is an effective alternative method to EFM that is easily used by midwives in a non-institutional setting. Intermittent auscultation
or (IA) describes regularly listening to fetal heart tones with a fetoscope or
an electronic Doppler for one full minute immediately following a uterine
contraction and counting in twelve (or more) 5-second samplings to determine
the baseline beats per minute (bpm). Using
IA, one can detect the presence of normal heart rate variability and
accelerations and, one hopes, document the absence of pathological
decelerations. The baby is considered to have a “reassuring” fetal heart
rate pattern if there is a normal baseline rate (110 to 150 bpm), normal
variability (6 to15 bpm variation in rate), normal accelerations (increase of
15 bpm, lasting at least 15 seconds & occurring two or more in 40 minutes)
and absence of repetitive pathological decelerations (decrease of 15 bpm, lasting
longer than 15 seconds). In the presence of a reassuring fetal heart tone
pattern, the likelihood of hypoxic states (i.e., fetal distress) occurring within the next 120 minutes
of normal labor is statistically insignificant (i.e., the baby's well-being is
assured). ["Fetal Monitoring In Practice"
by Dr David Gibbs &
S. Arulkumaran, MD; published in the UK]
It
is interesting to note that this method of beat-by-beat auscultation was the
theoretical basis underpinning the development of electronic fetal monitoring.
The original theory and method of fetal
surveillance comes from the work of Dr. Joseph DeLee, one of the titans
of modern obstetrics, who described counting and graphing fetal heart tones in
5-second sampling in his 1924 obstetrical textbook. [Principles
and Practice of Obstetrics; DeLee, 4th edition, ch. 8, p. 144]. Most
people wrongly assume that EFM is the equivalent of an electrocardiogram
(EKG) for the unborn baby but this is a serious misunderstanding of the
technology. Electronic monitoring is simply an elaborate mechanism to count
the unborn baby's pulse. The machine merely transposes the acoustic signal of
heart rate into a printed paper graph and video display of the four
auditory markers of fetal well-being. While IA is more time-intensive, it is equally as effective as continuous EFM for low and
moderate-risk labors, with the added benefit of a greatly reduced cesarean rate (4% vs. 26%). This
is, in part, because it unhooks healthy mothers from machines and
permits laboring women to move around freely. No longer tethered to the bed by
electronic wires, the mother is able to change positions frequently,
walk, use hot showers or deep water for pain relief and make “right use of
gravity” These practices reduce fetal distress and failure to progress
and the need for Pitocin-augmentation of
labor, pain medication, anesthesia and instrumental and operative delivery.
In
spite of the significant benefits of intermittent auscultation, the
obstetrical profession has dismissed the use of IA for what they claim
is the “unacceptably great expense involved in providing the one-on-one
nursing that is almost mandatory to perform intermittent fetal heart rate
auscultation.” [Obstetrics:
normal and problem pregnancies, Gabbe et al; 1992, p. 457]. This is a
strange objection, since many hospitals bill, and insurance companies reimburse,
$400 an hour for the use of continuous EFM, far less than the average L&D
nurse’s hourly salary. Luckily for the clients of midwives, one-on-one is
the standard caregiver-client ratio so IA is a natural, safe and
cost-effective extension of the midwife’s full time presence during active
labor.
The
majority of laboring woman in the US apparently do not object to the
limitations of medical management and increased cesarean rate associated with
continuous EFM. However, there is a significant minority of families who are
unwilling to tolerate an obstetrical “standard of care” that cannot
delivery on its promise of safety and satisfaction and for which the main feature is protecting
institutions from litigation by passing the risk on to the mothers and babies.
The
best, perhaps the only solution to the on-going (and all consuming) home birth
controversy is to make maternity care in homes and hospitals equally safe
and equally satisfactory so that families are not forced to choose home
birth for want of appropriate, compassionate and cost effective care in
hospitals. Obviously, it is beyond the scope of the MBC to rehabilitate
obstetrical care for healthy women or change our entire tort system. However,
the intent language of SB 1479 (2000 amendment to the LMPA) acknowledges the
right of healthy women to have control over the manner and circumstance of
normal childbirth, which includes not being forced into non-consensual
obstetrical treatment. While working for the rehabilitation of normal
maternity care, women must continue to have a reliable mechanism that permits
them to avoid the pain and potential harm of unnecessary medical and surgical
interventions without having to choose between an unattended labor or
untrained, inexperienced, or unregulated birth attendants. The intent language
of SB 1479 specifically addresses these issues. It states:
(a)
Childbirth is a normal process of the human body and not a disease.
(b)
Every woman has a right to choose her birth setting from the full range
of safe options available in her community.
(c)
The midwifery model of care emphasizes a commitment to informed choice,
continuity of individualized care and sensitivity to the emotional and
spiritual aspects of childbearing and includes monitoring the physical,
psychological and social well-being of the mother throughout the childbearing
cycle; providing the mother with individualized education, counseling, prenatal
care, continuous hands-on assistance during labor and delivery and postpartum
support; minimizing technological interventions; and identifying and referring
women who require obstetrical attention.
(d)
Numerous studies have associated professional midwifery care with
safety, good outcomes and cost-effectiveness in the United States and other
countries. California studies suggest that low-risk women who choose natural
childbirth in an out-of-hospital setting will experience as low a perinatal
mortality as low-risk women who choose a hospital birth under management of an
obstetrician, including unfavorable results for transfer from the home to
hospital.
(e)
The midwifery model of care is an important option within comprehensive
health care for women and their families and should be a choice made available
to all women who are appropriate for and interested in home birth.
Any action taken by regulatory boards that prohibits or
seriously restricts the ability of professional midwives to provide this form
of safe and non-interventive care ultimately denies the constitutional right
of healthy women to have control over the manner and circumstance of their own
normal childbearing experience.
The basic conflict between the mother’s right to choose
what many consider “unconventional” care from a midwife and the policies
of the Board was recently illustrated at a Medical Board settlement
conference. In this instance, a representative of the Board characterized the
midwifery standard as “dangerous” and insisted that the Board “would
have no part of it” and that the proper standard of care for midwives should
be the “same standard used by obstetricians”. Since midwives are neither
trained or authorized to practice medicine or surgery, there is no
question that potentially dangerous obstetrical interventions
should to be used only by physicians and only in an institutional setting with
emergency drugs and equipment at hand.
Because
of the inherent dangers in obstetrical standards of care, it would be legally
impossible for home-birth midwives to use the same “standard” as hospital
obstetrics. More to the point, women choose community midwifery precisely
because it doesn’t entail the restrictions, interventions and
complications of hospital based obstetrical care.
The appropriate relationship between the mother, the
professional midwife and the State of California should lie in making certain
that (1)
midwives provide technically competent, non-negligent midwifery care, (2) the
childbearing woman be provided with fully transparent information on all
identified risks associated with midwifery services and the planned
domiciliary labor and birth, (3) the childbearing woman and her midwife
document written consent for all routine care, (4) special informed consent with appropriate documentation be employed
for special circumstances
in which the mother declines standardized care, protocols or advice. In the
absence of “extremely rare and truly exceptional" circumstances that
present a clear and immediate danger, the legal standard requires voluntary
consent by the childbearing woman prior to any medicalization of labor. (ACOG case, District of Columbia Court of Appeals // In Re
A.C.. 573 A. 2d 1235 (D.C. App. 1990) Any lesser standard propels
mothers-to-be with certain moderate-risk circumstances into either unattended
or lay-attended labors or non-consensual and medically unnecessary cesarean
surgery.
I
believe the chronic misunderstanding of the Board and its agents about
midwifery and its standard of practice reflects the historical prejudice of
the obstetrical profession, which has seeped into the general consciousness.
For example, Dr. Thomas Joas, former president of the MBC and chairman of the
Midwifery Licensing Implementation Committee, stated repeatedly during the
seven committee meetings that he as a PhD/physician was a scientist who made
all his professional decisions solely on the most rigorous scientific evidence
-- unlike homebirth midwives who “had only had 2nd class
empirical experience and unscientific anecdotal evidence” upon which to opine.
His
opinion, based
according to him on solid science, was that “home delivery
was only for pizzas”.
On many such occasions, I had a sense that the
testimony of women, as mothers and midwives, was considered inferior to that
of men and physicians. Unfortunately, this type of bias is like a computer virus
that spreads from obstetricians to lobbyists to the press and the MBC staff
and members of the AG's office. The universal antidote for this type of
unconscious prejudice has always been corrective knowledge.
In
my opinion, the legislatively
mandated mission of the Medical Board – to protect the consumer –
includes an obligation to carry out the legislative intent of the LMPA. This
would mean protecting access to professional midwifery care in a domiciliary
setting for California residents. It would be virtually impossible to carry
out that mission and make intelligent decisions relevant to the oversight of
the licensed midwifery program without having knowledge of the historical and
contemporary science of evidence-based maternity care practices, which are the
essence of the midwifery model of care.
Expectation of Due Diligence by Board members
Relative to Licensed Midwives and Maternal-Infant Safety
I believe the level of due diligence that can be expected
of physician board members, who are PhD scientists in medicine, is the same as
one would expect in any other area of health care. In my opinion, the Board
has a due diligence obligation to be thoroughly familiar with the relevant
politics of medicine and midwifery and the last hundred years of scientific
literature on evidence-based maternity care, the principles of physiological
management of childbirth in a healthy population and the relative safety of
various birth settings. This would acknowledge that the consensus of published
research has established that community-based maternity care, as provided by
professionally trained midwives in conjunction with obstetrical referral for
complications, is statistically equally to that of hospital care under
obstetrical management.
I am impressed by the aptness of a quote in the foreword
of Davis’ Gynecology And Obstetrics textbook. It states: "There
is no alibi for not knowing what is known." (J. Rovinsky, MD, FACOG, 1968). I believe this
advice applies to professional midwives and obstetricians in regard to their
knowledge of evidence-based practice parameters and to Board members who
exercise regulatory authority over community-based midwifery. One hopes that
“knowing what is known” about this topic would bring to a close all those
conversations about whether or not domiciliary midwifery was “safe”.
The licensed practice of midwifery is not only lawful in
California but is historically and currently recognized in statute as a safe
and cost effective form of maternity care for healthy women. Mothers and
midwives and other interested parties are asking for the enthusiastic
assistance of the Board to help preserve access to this important form of
maternity care. The only other alternative is to turn back the clock, so that
once again the only way for families to receive, and midwives to provide,
domiciliary midwifery care would be under the religious exemptions clause
(section 2063), which has already been established as a lawful method
for non-regulated practice of midwifery. It should be noted that midwifery
practice under section 2063 does not require
physician supervision.
As
a Mennonite midwife, I could easily resume my former caregiver activities as a
religious practitioner. However, I am convinced that what best serves
mothers and babies and the State of California are well-trained,
experienced, fully-equipped professional midwives who are properly articulated with
medical services, so that complications can be promptly and appropriately addressed.
For this and other reasons we need the LMPA to be
protected from attempts by the medical lobby to encroach on its functionality
or to eviscerated its authority. We need the MBC to support the right of
healthy women with normal pregnancies to make informed consent decisions about
the manner and circumstance of normal childbearing, even if some of those
decisions are medically unpopular. We need the MBC to robustly implement the
Licensed Midwifery Act of 1993.
A useful example of the "right
relationship" between the midwifery and medical professions, one that
serves the long-term interests of society, is encapsulated by the Society
of Obstetricians and Gynaecologists of Canada' Statement on
Midwifery, No 126, March 2003. Midwifery in Canada is an independent
profession, in which registered midwives are required by law to provide care both
in home and in hospitals. These statements on midwives and
community-based midwifery care are in sharp contrast to the policies of the American
College of Obstetrics and Gynecology .
Passages from the Society of Obstetrics and Gynaeology
of Canada read:
The Society of Obstetricians
and Gynaecologists of Canada (SOGC) supports the continuing process of
establishing midwifery in Canada as a regulated, publicly-funded profession
with access to hospital privileges. ….
The SOGC will extend membership to registered midwives and offer them access
to ongoing educational experiences.
…. The SOGC recognizes that
women will continue to choose the setting in which they will give birth. All
women should receive information about the risks and benefits of their chosen
place for birth, and should understand any identified limitation of care at
their planned birth setting. The SOGC endorses evidence-based practice and
encourages ongoing research into the safe environment of all birth settings.
The SOGC believes midwives
should be integrated members of the maternity care team in their community and
hospital. .... (2) Development of policies and procedures to ensure
smooth integration of patient care between midwives and other obstetrical care
providers.
The SOGC is confident that the integration of midwifery into the
obstetrical health-care team is fostering excellence in maternity care for
Canadian women and their families, which is the goal of our organization.
I believe the scientific literature I am providing
to DOL members and agency staff will be an important tool for the Board in
achieving these worthy goals.
Thank you for your attention to these matters. I look
forward to an improved and dynamic relationship between midwives and the
Medical Board of California.
Faith Gibson, LM, CPM Executive Director,
ACCM/California College of Midwives
CC: Letter and two-notebook set of scientific
literature sent to:
Each members of the
MBC/DOL,
Executive Director,
MBC,
AG / Health Enforcement Office
Senator Figueroa’s Office
John Kennedy, Attorney
Frank Cuny, CCfHF
Carrie
Sparrevohn, CAM
Renee
Anker,
CALM