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Recommendations -- Roberta Devers Scott
NY Sentencing HearingWhat will and won't work
files cited are available by clicking here
Waiting for the problem to go away by itself won't work because Power doesn't ever give itself away. The medical campaign to eliminate the competition of midwives was cleverly crafted, inter-generational in time line, without scruples and has unlimited funds available to it. These powerful medical politicians can just sit tight and wait for unlicensed midwives to be "eliminated" by criminal arrest. They can patiently wait for licensed midwives to be driven out of practice because we are locked out of the system of 3rd party payments and/or because midwifery reimbursement is not included under HMOs or future national healthcare plan. As every good midwife knows from those occasional labors that just don't progress, more of what isn't working (sitting tight and waiting) won't work either!
I suggest that midwives must win in the same place that we originally last -- that is the Court of public opinion. We must win first in the court of public opinion before we have a real chance of prevailing a court of law. And until we win in the courtroom, we cannot expect to be successful in achieving lasting legislative reform. Even as short a time as 20 years ago, it was almost impossible to prove statements about the safety and efficacy of the midwifery-model of care by citing reputable scientific studies and statistics. Not because such data didn't exist but because the bits and pieces of this puzzle were spread all over the world literature. Unless one had a Ph.D. and devoted one's life to such research, it was beyond the means of us as midwives and our professional organization to get our hands on the proof. Thanks to the information highway, this is no longer the case. A virtual mountain of historical material exists. {link}And equally important, a matching mountain of modern day research, {link}conveniently recorded in Henci Goer's book "Obstetrical Myths Versus Research Realities" and Marden Wagner's book "Pursuing the Birth Machine". The Cochrane Data Base notes the absence of any scientific validation for routine obstetrician care and hospitalization for normal maternity services. Knowledge is still power and we have the blessing of that knowledge and many different avenues to distribute it widely.
Public Information Campaign
Reverse the purposeful public dis-information campaign by mounting a public information campaign, in particular, through use of the information highway -- the Internet being the pearl of great price. The concept is simple enough -- the truth does not have to be defended, only revealed. The truth is that home-based midwifery care (historically and in contemporary times) is as safe or safer than hospital-based, interventive obstetrics. The best pregnancy outcomes are associated with the use of a midwifery model of care for healthy mothers and utilization of obstetrical care for complications.
Medical politicians have cast a spell over us for the last 100 years. In recent years, they have been able to manipulate public opinion even more effectively through saturation TV. One need only watch the way childbearing is portrayed in film and on televisions to know how deep is our "pre-cognitive commitment" to the erroneous idea that birth is a disaster looking for a place to happen.
We must think in terms of casting a new spell through art and literature, such as short stories, novels and the like, with a special focus on the medium of video. We need midwifery-oriented scripts for soap operas, sit coms, made-for-TV movies and someday, major Hollywood films. We need to produce teaching tapes that permit us to trickle the sights and sounds of normal, midwife-attended birth into the culture again. We need prototypes videos to be sent to film makers (for instance, George Lucus is interested in using film as an educational medium). We need to invite celebrities such as Richard Thomas, Bobbie McFerin, Pamula Hunt and others who have had homebirths to speak at midwifery events and to speak out to the media in support of midwifery.
Totally Birthing Barbie for Generation "X"
And on the totally fun, totally great teaching tool side, circulate copies of the video made by midwifery students at Seattle School of Midwifery in which Barbie and Ken have a home birth! For those of you who haven't seen this home-made, homebirth video, it is 12 kinds of wonderful. It was shown at the October.96 MANA Conference and is the perfect answer to how we are going to get the message of midwifery to the "X" generation (not to mention the younger people now working in the news media!). I particularly liked seeing Barbie on sitting on the toilet pushing with Ken kneeling beside her, then giving birth on her hand and knees (with a tiny little brown-haired baby peeking out of her vagina!) and "sister" Skipper cheering her on! The best line came at the end when she is nursing the baby and says in her Valley girl voice "Now I finally know what my breasts are FOR!"
Widen the base of midwifery politics
We must widen the base of midwifery politics to include the whole spectrum of the American population -- men, single women, older couples, children, elder Americans and others. We need to talk about how a midwifery model of care in the US is an advantage even to people who themselves will never have a baby.
How home-based midwifery care promotes local employment
We need to be able to discuss how a midwifery-based model of maternity care would have a positive financial impact on our own communities. Money saved by the homebirth family becomes available to pay for local services such as hiring a carpender & electritian to remodel kitchen or build a room on to the house, buy new appliances, hire a maternity aide, help with housework, put the kids in private school and many other possibilies. Hospital-based birth services costs between $4,000-8,000 and the big bucks go to hospital corporations and insurance companies (and CEOs who make multi-million dollar saleries!). In contrast, midwifery care usually costs between $1500 to $2500 and directly benefits our communities thru ;right livilyhood ; for the midwife and her family and by keeping the $2,000 to $6,000 difference in the control of the childbearing family. So make friends with your local trade unions and offer to speak at one of their meetings about the what cost-saving means for them personally.
Issues of healthcare policy and Ever more scare healthcare dollars
We must connect the midwifery model to the wider issues of healthcare policy and ever more scare healthcare dollars. For instance, retired persons frequently face the gut-wrenching financial and ethical dilemmas of our badly broken medical payment system. Start thinking of the AARP as our friend. The finite nature of the healthcare dollar makes it necessary to admit that money unwisely spent on healthy mothers and babies means less to spend when a non-pregnant loved one have a true medical crisis. I experienced this personally when my younger sister had a life-threatening head injury. While she was unconscious in the ICU 48 hours after major brain surgery, the hospital pushed for permission take her off the respirator. I am happy to say my sister did not die 4 years ago because we all refused to let her be ;unplugged ;. Her injury was almost fatal -- not because of the severity of the brain damage or blood loss (all properly treated) -- but because she was uninsured!
Hospitals make 38 cents profit on the dollar for maternity
Versus only 5 cents for cardiac surgery.Expose the cost shifting mechanisms inwhich healthy childbearing families being called on to cover the less "profitable" hospital care .Hospital make 38 cents profit for every $1 charged for maternity care but only 5 cents profit per dollar received for cardiac surgery. Billing young families for care received by others is a very unfair way to pay healthcare costs. If it were widely known, it would help citizen groups working for changes recognize the contribution that midwifery has for everybody.
Maternity care -- Most frequent Reason for Hospitalization in the US,
and Most Profitable Department of the HospitalThe single most frequent reason for hospitalization in the United States is childbirth. Maternity departments are the most profitable area of the hospital. To quote Hospital Administration Currents: "Obstetrics is now considered to be the service leader in establishing patient loyalty to the institution. Innovative maternity programs can increase the patient volume in other areas, through the women's influence. Since women tend to decide where the family will go for medical care (70% say some researchers) loyalty won through innovative obstetrics programs transfers to other patient areas. Studies show that a positive hospital experience for maternity care leads to continued usage of that medical facility by the family consumer group. Initial equipment and construction costs can be offset by...an increase in revenues due to volume changes." ["Innovations in Obstetric Design" Hospital Administration Currents, 1986, 30 (3); 9-14] For about the last 10 years, conventional "wisdom" in the hospital industry has identified maternity care as the "cash cow". Turning childbearing women into :marketing strategies" is not a very flattering or ethical relationship to have between the healthcare industry and ourselves (unless they want to pay us for having our babies there!).
Utilize the Statistical Superiority of Midwifery
to Influence Insurance CompaniesUtilize the statistical superiority of midwifery to influence insurance companies in the direction of midwifery care. The company that reimburses for the lower costs of maternity care, can charge the lowest premiums, gain the larger number of enrollees and thus develop a genuine business advantage. The global economy gives an advantage to countries that have a lower expense of doing business, including the cost of healthcare. Those countries who are not throwing giant quantities of scarce healthcare dollars down the rat hole of high tech obstetrics for healthy mothers, can undercut the US who, at this moment, is locked in an addictive relationship with the blackhole of unnecessary and unwanted medicalization of perfectly healthy mothers and babies.
Professional Education for the "Gatekeepers" of Public Opinion
We must reverse the dis- and mis-information that holds the physician community tightly in the grip of its prejudices against independent midwifery and home-based maternity care. Our problem is not primarily doctors but the medical politicians who will exploit anyone and anything -- including physicians -- to gain an unfair advantage. The hospital industry has targeted maternity services as the cash cow of the hospital business and now holds a gun to the heads of ob doctors, threatening them with lost of hospital privileges if they have any thing to do with homebased care. If we give these physicians the kind of accurate information that counteracts the pre-cognitive commitments of medicine, we can better solicit their co-operation and also empower physicians to resist the exploitation of the hospital industry. Nurses, EMTs, Lawyers, Judges, Legislators, Politicians, Journalists, Reporters In addition to physicians, other professionals such as nurses, EMTs, lawyers, judges, legislators, politicians, journalists, reporters should be first in line for community-based midwifery education. These people are the ;gatekeepers ; of public opinion, they stand at the gate deciding what ideas do and do not gain admission to public conscience via the media and the court of public opinion. We need to develop information packets, short professional presentations and informative videos that can be presented at local meeting of clubs or professional associations to counter the pre-cognitive commitments pervasive in our culture.
The Mother Friendly Childbirth Initiative
The Mother Friendly Childbirth Initiative can provide us with a good ;excuse ; for making these contacts with our local hospital and generate a staring point for an on-going dialogue. We must become pro-active and the MFCI is a particularly useful place to start.
Bold and Creative Use of the System
Learn the bold and creative use of the legal system.
I am told by respected legal experts to be proactive. It is a near-fatal political mistake to only utilize legal services when we are being criminally prosecuted. We need to use injunctions to stop the use of the medical practice act and midwifery licensing law -- both of which are based in the concept of providing "public safety measure"-- from being used illegally as a mechanism of anti-trust and unethically to force childbearing families into risky unnecessary and unwanted hospitalization.
Bold and Creative Use of the Legislative System
We must develop a high-level understanding of the legislative system. For instance, in many states, we can ask for a legislative oversight hearings when the legislation we sought out to protect us and make midwifery more widely available is instead being turned against us. We have as much scientific validation as the anti-smoking campaign. A small but well-equipped harem of credentialed men such as Marsden Wager, Marshall Klaus, Michael O'Dont, James Prescott, Joseph Chilten Pierce, etc. are willing to be expert witnesses, write letters, give testimony and otherwise re-educate through the news media.
Delegations of Concerned Citizens
On both a local and state level, we can put together a delegation of concerned citizens who regularly visit the offices of legislative representatives, introducing themselves and the concepts of the midwifery model and educating the legislative staff before any specific legislation is pending. Making a personal connection, knowing the faces that go with the names, is very effective in political realm. In the event of a criminal prosecution or inappropriate actions by regulatory boards against homebirth physicians and midwives, we can organize small groups of 6 or so volunteers who go personally to the DA's office or regulatory agency, perhaps every day for a week or every week until appropriate action is taken. We must convince officials that real people really care and we won't let our caregiver be scarified on the alter of inertia.
NARM Job Analysis, NAFTA & the
Legal Basis of Midwifery PracticeLobby state agencies for recognition that midwifery practice MUST be based on midwifery practice -- the NARM job analysis legally establishes the actual legal job description of non-nurse midwives. Use civil rights and other constitutional avenues to insist that only "transparent criteria" such as "competency, and ability to perform the service" is the basis of any licensing scheme.
For instance, the North American Free Trade Agreement prohibits unduly burdensome licensing law and regulations. According to a letter from the United States Federation of State Medical Boards, written in January 1994, "State medical board licensing standards are not pre-empted from the free trade agreement. NAFTA's objective in relation to licensing is to prevent licensing requirements from being "unnecessary barriers to trade". NAFTA specifically forbids "anti-competitive" licensing requirement which constitute a disguised restriction of the provision of services.... specifically disallows any licensing or certification statues, regulations or procedures which are not based on objective and transparent criteria, competence and the ability to provide the service or which are more burdensome than necessary to ensure the quality of the service." Leave no stone unturned!
Citizen Oversight of Medical and Midwifery Boards
Make attendance at Medical Board and Midwifery Board meeting a national past time for midwives and other traditional health caregivers. In regard to health care, especially relating to ;alternatives ; such as midwifery, these public meeting are the most important regularly-scheduled events of state governments. It is a must-not-miss opportunity that costs nothing. In my own state, the Medical Board makes policy for 31 million residents and yet I am often the only private citizen at their meetings.
There should be dozens if not hundred of people at every meeting as "physician supervisors".Video Taping Regulatory Boards Meeting
Since we aren't likely to get hundreds of citizens to participate directly, video tape all board meetings (including midwifery board) for distribution. The other benefit is that it makes members of the Boards think twice about what they do and say as it is being recorded on tape and can be distributed to the media. It is similar to the improvement seen when we have a knowledgeable witness (i.e., doula/patient advocate) present at hospital births. The politics of doctoring benefits from the presence of a doula as well!
Fourth US Bio-ethics Commission
Lobby for a community midwife to be appointed to the 4th US Bio-ethics Commission. This US commission was first appointed about 20 years ago to investigate the Tuskeegee experiments, in which poor black men with syphilis were denied treatment for their disease so that scientists could study the untreated course of this disease over a 30 year time-frame. As a result of this repugnant and amoral policy, the Bio-Ethics Commission developed the ethical guidelines for experimental medicine that are currently employed. Until then, (1976) the medical community was not required to tell patients when experiments treatments were being recommended or used on them and they did not need to solicit their voluntary participation to be used as subjects in the testing of drugs and medical/surgical procedures.
This is actually why obstetrical medicine for healthy mothers, which is clearly "experimental" by every measure of such definition, achieved such total acceptance without having to prove the efficacy of its interventions. These experimental interventions and policies continue to be accepted by mainstream medicine simply because they represent what is "customarily done ; or the ;community standard of care ;. However, as mothers and midwives and other citizen supporters of independent midwifery, we can push for investigation of this on-going situation as well as why the midwifery-model of care is not being implemented in the face of such overwhelming evidence of its greater efficacy. Work for the appointment of a Blue-Ribbon panel in each state to embark on a fact-finding investigation of mother UNfriendly maternity care and barriers to midwifery care.
Political Networking with the Healthcare Freedom Movement
Political networking with the healthcare freedom movement such as the national organization ;Citizens for Health Freedom ;. All of us together -- acupuncturists, chiropractors, preventive health practitioners, nutritional counselors, health food business, vitamin manufactures, and of course midwives -- are a lot of clout together that none of us singularly can muster. New York in particular already has been successful in getting the Medical Practice Act amended so the use of ;alternative ; treatments by licensed healthcare provider are not illegal (nor considered unprofessional conduct).
$$$$$$$$$$$$$$$$$Money$, Money$, Money$$$$$$$$$!
Be serious about a ;war chest ; -- effective political action is not cheap! Every practitioner needs to contribute a minimum of a $10 a month and those of us who attend more than a dozen births a year should contribute the equivalent fee of one birth to the coffers of our state and national organizations such as Citizens for Midwifery, MANA and the like.
"There can be no alibi for not knowing what is known"
-- Foreword to the Davis Obstetrical Textbook, 1966Give physicians some additional "incentives" to incorporate midwives into the "big plan". We have a winning strategy and we'd like a win-win outcome. In particular, nform the policy makers of ACOG that it is just a matter of time before trial lawyers bring midwifery into the courtroom as the standard of care for normal birth. When this happens, obstetricians will be held accountable for failure to be knowledgeable of, trained in, and use these common-sense methods as the standard for healthy mothers experiencing normal pregnancies.
We must hold physicians responsible for knowing the principle of midwifery management and routinely utilizing midway skills before embarking on medically and surgically risky interventions. Obstetricians have three ethical choices. First will be to recommend that changes). Second, obstetricians can chose to employ "co-management midwives" who will independently provide normal maternity care to low and moderate risk mothers at the hospital. Third, obstetricians can personally take up the study of midwifery and labor sit themselves, personally providing healthy mothers the "midwifery standard of care".
Failure to do thiswill mean facing malpractice litigation for failing to provide "appropriate" care each time they order pain medication for mothers who have no emotionally supportive labor companion; for using pitocin without first using maternal ambulating and common-sense labor stimulation techniques; for using forceps and vacuum extraction without first trying vertical postures; squatting and other gravitationally-appropriate positions; for doing the Zanvanelli maneuver without trying hand and knees and other simple techniques to dislodge a shoulder dystocia. The most satisfactory solution will be for obstetricians to acknowledge that they are trained for and skilled as surgical specialists in the complications of childbearing, which has very little to with ;normal ; and uncomplicated birth.
Midwifery and obstetrics are two very different disciplines with two very different scopes of practice. While each shares an underlying foundation in biology and has some areas of overlaying responsibilities, they are not based on the same education preparation nor the same temperament.
Elanor Rossevelt quote cooperation physicians and midwives
Epilogue
It is so important that midwives and citizen groups not become discouraged and passive. There are so many avenues of action that we can employ. What we don't have, however, is a simple one-step solution. When counteracting an evil that has been so big, so broad, so deep, and so long, we cannot expect a quick fix. The original medical plan for midwifery was "death by a 1000 razor cuts" and its antidote will have to be life by a 1000 points of light and love. We must not loose heart or our sense of humor. One advantage of such a deep-seated problem is that it calls on us to be boldly and courageously creative.
Personally, I suggest thinking in terms of being ombudsmen not only for ourselves and childbearing families but also for physicians who are themselves being exploited by the forces of organized medicine.
May this ignoble chapter of history be won over by our good nature, mutual good will and a sincere desire for a win-win solution!