May 3

Moved from Home Page -- Information published before the on July 29th, 2005 Hearing

May 3, 2005

California College of Midwives
Report on MBC Task Force 4/27

The good, bad, the ugly and............ the Bottom Line ~But first, a synopsis: The Board tabled the currently proposed regulation. Tabling means that the current regulation is still the one we are working with. Specifically when the Board tables a regulation that is `in `play' it means that: (1) they did not take an up/down vote on the regulation (2) they did not kill it or decide to `start over' However, in the future they may still: (a) kill it, (b) pass it on for the consideration of the DOL by voting on it (c) decide to change it or even to start over. The Board did not decide to reconsider the MANA documents. However, ACOG district IX rep Dr Haskins agreed to take and read a copy of the 3 MANA documents and provide an official ACOG opinion on the use of them in place of sections one and two of the CCM document. Stay tuned. The most important issue at the Task Force meeting, from the Board's prospective as a regulatory agency, was the cesarean prevention issue -- breech, twin and VBAC. Politically speaking, the Board is hoping that LMs and ACOG can arrive at a mutually acceptable consensus so that they will not have to make a "Solomon" like decision. ACOG's District IX official and formal position is steadfastly to oppose midwife-attended breech, twin and VBAC labors. ACOG claims that the LMPA prohibits midwives from providing care to women with moderate risk pregnancies, even if the mother exercises her right of informed refusal. In other words, they support unattended births and the re-creation of lay midwifery. However, the ACOG reps would like to help us find an truly acceptable middle ground. The Board is (and will continue to be) `risk-adverse', which means they must have a nearly fool-proof process for letting themselves off the hook should the final decision formally acknowledges breech, twin and HBAC in the midwifery standard of care. Eventually someone somewhere in the state will have a `bad outcome' with an LM-attended labor or birth in a special circumstances pregnancy. And then they will show up at a Medical Board meeting to accuse the Board of malfeasance for "having permitted a licensed midwife" to attend their breech, twin or post-cesarean labor. This is why the "informed refusal" is so important, as it acknowledges the California and US constitutional right of mentally competent healthy women to exercise self-determination in childbearing, a civil right that supersedes the regulatory authority of the Medical Board (thus protecting the Medical Board as much as it does the mother and midwife). In regard to the progression of midwifery politics, I am particularly impressed with the legislative gains in other states that has occurred since the LMPA was passed here 12 years ago. In spite of increasingly `conservative' red-state dominated national politics, none of the states that have passed licensing laws since the LMPA in 1993 (Colorado, Tennessee, Utah, Virginia, etc.) have required supervision and none of those states with pending midwifery bills mandate supervision (Wyoming, Wisconsin, Massachusetts, Nebraska, South Dakota, Missouri). Except for New York, no other state requires supervision and yet, ACOG is a national organization and is in all these other states (in other words, it's acceptable to ACOG that 22 out of 24 states with licensing do not require physician supervision!). As for VBACs, both New Hampshire and Colorado specifically acknowledge the legal provision of care by midwives to VBAC mothers, a situation also accepted by ACOG. Texas and other states actually have midwifery boards composed primarily of midwives. Its clear to me that it is to ACOG's benefit to climb down off their high horse and begin to develop a 21st century attitude toward midwives. Now for the Good news: For the last 11 years, ACOG has exercised a great deal of abstract influence over midwifery-related matter but has mainly shown up as missing in regard to being an interactive presence. Since I approached Shannon Smith Crowley (ACOG lobbyist) at the February Hearing, we have been able to forge an increasing dialogue between midwives and ACOG representatives. That process was expanded at the conclusion of the Wednesday meeting to include an e-mail discussion group between CAM, CCM, CALM and ACOG in regard to the issue of defining an `appropriate' standard of care and of even greater importance, cesarean prevention -- twins, breech, and HBAC. This is vital, because we can never develop a stable base for the practice of midwifery without the cooperation of the medical community -- both MBC and ACOG. The notion that we can go around them, over them or thru them is just not realistic -- we have to go with them together towards a mutually workable solution. I believe that ACOG's presence in the capacity of a facilitator has been a major missing piece over the last eleven years. During the year-long process of implementing the LMPA, which consisted of seven day-long meetings at the Medical Board, ACOG refused to send a representative. (These meeting were held in the very room we occupied Wednesday and attended regularly by Maggie Bennett, Maria Iorilla, Tosi Marceline and myself, as well as other midwives no longer active in midwifery politics.) In the minds of the midwives who attended the implementation meetings, ACOG's absence reinforced its position as one of total disdain for midwifery -- a kind of "we don't do windows, we don't do midwives, and we're hoping you all will just drop dead or move out of state or get arrested or something so we never have to deal with you again" impression. This message was bad for midwives, bad for mothers and bad for the medical community. Most especially, it meant that 100% of the Medical Board members and agency staff in charge of the midwifery licensing program had no personal or professional experience with midwives or normal birth. At the same time, they all shared the cultural prejudice that community-based midwifery care was irresponsible on the part of the midwife, was a hedonistic indulgence (or ignorance!) on the part of the parents and that the LMPA has been a `mistake' on the part of the California legislature. Many MBC members and staff thought that if they just waited long enough, organized medicine would `eliminate' their problem by eliminating licensed midwives, so they had little incentive to foster cooperation. ACOG's functional absence in this process resulted in many crude and counterproductive attempts by the Medical Board to regulate midwifery with a brick bat in areas where mutual cooperation or, at the very least, the light touch of a feather would have been far more effective. This produced a big backlash against the Medical Board by LMs (as expressed by a 99% vote against the MBC Wednesday!). It also permitted many in the midwifery community to discount the legitimacy of ACOG's point of view and get in the habit of thinking that ACOG had no business `meddling' in matters of midwifery licensing or practice. While I attended all the Medical Board meetings during this same 11 year period of time, the agency staff did not have any legislative or administrative mechanism that permitted them to consult with or include me or other representative of LMs in even the most mundane aspect of the decision-making process. As you all already know, midwives are legally prohibited from being appointed to the MBC and we have no standing "Midwifery Committee" (a `task force' is by definition disbanded each time it's `task' is accomplished). So the policy-making and implementation process for LMs has often been in the hands of newly-hired, low level bureaucrats with little or no understanding of, or sympathy for, midwifery. And every 6 to 15 months, the MBC replaces this employee with a new and inexperienced person so there is no continuity or `institutional memory'. This has made life uniformly miserable for midwives while failing to exercise effective oversight on behalf of consumers. Because the LMPA substituted physician supervision (which isn't available and doesn't work) for Medical Board oversight (which would) the Board's current method is to wait for a bad outcome to result in a formal complaint. Each `bad outcome' (whether preventable or not!) reinforces the Medical Board's prejudice that normal birth is dangerous in the hands of mothers and midwives. So I am pleased to have attended the funeral of the "bad old days" of ACOG as a negative force and to celebrate a new way for a new century. I hope that with the continued participation of the Shannon Smith-Crowley and Dr Haskins, as well as Sacramento obstetrician Lori Gregg's appointment to the DOL (and one would hope, to a standing Midwifery Committee!), that we could improve the functional relationship between LMs and California obstetricians. The Bad: We did not "win" as in reaching the finish line. The easiest political strategy to accomplish is to propel the Medical Board to "table" something. The real deal here will be what happens next. The Ugly: The unhappy truth here lies in three areas. First, the level of political sophistication of midwives is generally low and needs to be greatly improved in the near future. Midwives (even those who don't personally attend medical board meetings) need to understand the philosophy // politics that motivate the actives of the Board (a preference for control and overriding need to avoid embarrassment // public humiliation!) and the specifics of the legal processes for passing and implementing regulations. For example, once the text of regulatory language is sent out as a "notice", it cannot be modified until the actual hearing is held. This kind of understanding will be help to midwives and to the Board and keep many of us from becoming so frustrated. Secondly, neither I nor other CCM members are going away and that is not "bad". I would suggest to midwives that this is not a tragedy -- in fact, the differences of opinion that we represent are helpful, they engage midwives in useful dialogue, they help to `further the action' in many places (Board, legislature, etc.). I would also suggest that the often- repeated idea of unity as promoted by many CAM midwives is a thinly veiled assertion that I and all other CCM members and sympathizer should simply acquiesce to CAM's preferences for the dubious benefit of `consensus'. That's not the strong unity of compromise but rather of a phony consensus that results from stifling debate. I've been an up-close and personal "Medical Board Watcher" for 12 years and can report that all parties to the Medical Board authority come in different flavors and so far, it has not prevented the Medical Board from (sooner or later) making appropriate decisions and taking action. And I might point out that the place that "consensus" really did matter -- agreeing to voluntarily give up the right to provide care to VBAC mothers -- 100% of LMs voted it down instantly, on the spot, without a word of discussion among ourselves. Three -- the CAM-CCM controversy. I think the message is clear -- CAM has not been meeting the needs of the majority of California LMs. An easy measure of that is the number of midwives that never or no longer belong to CAM -- a membership of only 50 out of approximately 150 LMs is very telling. Only 22 CAM members attended the CAM board meeting last Friday evening at their annual conference. My personal experience with CAM has been that anyone who `disagreed' with CAM leadership was sent to the dog house or wood shed. For me that disagreement revolved around the idea that unless one was designated as a `team player" by CAM's ruling elite, then one was not "allowed" to participant in the political process or ostracized if one insisted on pursuing political action. It seemed strange to me that an organization of `pushy women' would be so punitive to one of their own who was `brazen' enough to be push back within the organization. After a several years of being the `bad girl', I decided to take my business elsewhere. More recently, the controversy for me has centered on the medical board and the tension between national versus state control of California licensing issues. However, there are other midwives who do not feel served by CAM's brand of midwifery politics, for whom the issue is the intense "goddess" focus that imbibes CAM events. This is a real turn off to many observant Jews and Christians or to LMs who are basically secular and don't want to begin every public meeting by holding hands and singing "Sisters on a Journey". It may be that CAM members so disposed towards woman's spirituality feel so strongly about the benefits of having this one place in the world (CAM meetings) that acknowledges this aspect of their `spiritual' beliefs, that they would vote to "bifurcate" the organizational aspect of midwifery politics from the social aspects. The membership of the California College of Midwives is fast approaching that of CAM's and consists primarily of LMs who also do not find CAM to be meeting their needs as California LMs. Eventually, the CCM membership will exceed that of CAM unless CAM can make the necessary changes and begin to address the dissatisfaction, instead of attempting to deny or stifle alternative voices. While I am presently both founder and director of the CCM, I suggest that over the next five years, CCM membership may well rise to a majority of LMs and were that to occur, strong consideration should be given to melding CCM and the political aspects of CAM into a single organization with an elected leadership and advisory board, while preserving the social structure of CAM separately for its own value. Bottom Line: We are in a `holding pattern' in regard to the MBC, while facing an exciting opportunity with ACOG to move us past the `grid-lock' of the last decade. As for the politics of this, each midwife must choose for herself to either to be personally present and politically active or, by their absence or their expresses wishes, delegate decision-making to those of use who are present. This is not the first time midwives have had this hard choice -- only about 20 midwives ever came to the 40-plus hours of committee meetings during the implementation phase. Less than 10 of these midwives actually stayed the course. And yet, midwives did not think of these activists as doctorial or despotic but generally appreciated them for their efforts. warm regards, faith ^O^

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The official letter from the MBC informed California LMs that the Board was planning to proceed with its recommendation that Sections 1 & 2 of the CCM Standard of Care to adopted by reference as the identified standard for California LMs.

         However, I also received a copy of ACOG's letter to the Medical Board, in which they state the opinion that providing care to certain clients, such as those with a twin pregnancy, would be an illegal practice of medicine.

         They also are requesting over a 100 changes to the CCM Standard of Care. Some of those have to do with minor formatting, some requiring re-organization of the document, and many substantive changes that would drastically re-define our scope of practice in the following ways:

          Deletes reference to "well-woman gyn care" and definition of "Normal birth", deletes all reference to breech, twin, VBAC, PROM, GBS protocols, defines 42 wks as requiring transfer of care, regardless of fetal status, requires multiple home visits to assess the 'appropriateness' of the clients home for a planned labor and birth, requires the client to consult with a physician on the LMs recommendation, deletes all informed consent document references, changes many of the 'suggested' guidelines to 'must', adds in the words "within the scope of practice" to many guidelines, etc, etc, etc. The point is this is no longer a midwifery-based standard, but rather protocols for homebirth obstetrics as a specialty chapter of ACOG.

         At present the Medical Board staff are also attempting to re-write the CCM document so that it integrates all the comments made at the February Hearing. Obviously, this would no longer be a CCM document and so they would have to remove all references to a "California College of Midwives' Standard of Care", since this would now become a MBC standard FOR licensed midwives.

         The new regulatory hearing for proposed Standard of Care is 9 am,
         July 29th at the Radisson Hotel, 500 Leisure Lane, in Sacramento
         (go on MedBd web site for additional info www.medbd.ca.gov )

                                                                              Be there or be square.

Conservative & Responsible Maternity Care

I am not old enough to remember what it was like when the physiological care of midwives was norm for normal birth, but I am old enough to have been a hospital labor and delivery room nurse when maternity care was primarily provided by GPs. Obstetrician-attended birth were in the minority and that choice was usually associated with doctors’ wives and care of the very wealthy.

The management style of general practice doctors was conservative, as defined by the classical principles of conservation. In regard to childbirth, the ability of the practitioner to bring about a vaginal birth was seen as a value, while Cesarean section was rightly seen as a dangerous procedure to be used sparingly and then only when all other avenues had failed. The older GPs had trained in the 1930s and 40s and began their practice when the majority of childbirth still occurred at home. These older doctors had a history of working with midwifery assistants who proved the bulk of the labor care at home at the direction of the GP and in some cases, simply conducted all the normal births themselves, with the physician only being called in when there was a medical problem.

As a labor room nurse in the early 1960s, I routinely saw GPs and obstetricians deliver breeches and twins vaginally, with little or no ‘special’ attention or preparation. Both of these situations were considered a variation of normal vaginal birth and the outcomes for these mothers and babies were consistent with those of other normal vaginal births. Even complications such as a marginal placenta previa were managed “conservatively”, with the professional skill of the practitioner informally judge by his ability to avoid a Cesarean. Except for emergency C-sections, all intrapartum Cesareans required the physician to get a second opinion and the doctor consulted with could not be a part of the same group practice. Every Cesarean performed was reviewed by the obstetrical morbidity and mortality committee meeting each month. Any physician whose C-section rate was substantially above average was cautioned and if the rate stayed too high, would be put on probation (which required a proctor physician to work in conjunction with him) until the rate was not brought back into line with the overall norms for the institution. In 1961 our hospital had a 3% Cesarean section rate.

Deconstructing Conservative and Responsible Maternity Care

During the first ten years of my L&D nursing career, I noticed the incremental elimination of GPs from the pool of physicians granted obstetrical privileges. During the decade of the 1960s, the scale tipped slowly towards a majority OBs, but still a fair number of the older GPs who were well known and well liked in the community. By the 1980s the GPs were gone but a few new non-obstetricians from the newly minted ‘specialty’ of family practice medicine were providing maternity care.

However, the scope of practice of family practice doctors was incrementally restricted over the next two decades by policies passed by the hospital obstetrics department. The chief of OB, who is responsible for the OB department policies, was always elected by a vote of the physicians with obstetrical privileges. As board-certified (ACOG) obstetricians came to dominate the obstetrical staff, the majority of doctors predictably choose an obstetrician each year to be chief of staff. It has been a century-long agenda of the obstetrical profession to reduce the number of non-obstetrician providers of childbirth services. This resulted in increasingly restrictive policies, as non-obstetricians physicians were no longer permitted perform Cesarean surgery (even though they were licensed as ‘physicians and surgeons’) and also prohibited to attend breeches or twins or VBACs.

The return of Conservative and Responsible Maternity Care

Aside from the ethical principle of the autonomy of healthy and mentally competent adults is the disturbing issue of an obstetrical profession that is apparently being held hostage to a radical form of maternity care for healthy women, which seeks to make surgical birth a ‘standard of care’ for the obstetrical profession. Due to policies set by hospital obstetrical and anesthesia departments, obstetricians are being restricted to a level of obstetrical care well below that of first year obstetrical residents or the tradition practice of midwives around the world. Obstetricians now need a permission slip from the hospital administration or chief of the anesthesiology department in order to provided care for a planned VBAC. In many case, obstetricians are forbidden, through formal or informal OB department policies, to provide vaginal birth services to mothers with a twin or breech pregnancy. (This also applies to providing backup services to midwives or accepting hospital transfer of home birth clients.)

The result of a disenfranchised obstetrical profession is a sky-rocketing C-section rate, which in my professional life (1961 to the present) has gone from 3 to 27 percent. Identified risks of cesarean includes 33 well-known complications (including a 13-fold increase in emergency hysterectomies) compared to only 4 specific risks for normal vaginal birth [see MCA’s systemic review “What every pregnant woman needs to know about Cesarean Section” at www.maternityWise,org]. Childbearing women who are delivered by Cesarean section are two to four times more likely to die from the intra-operative, post-operative or downstream complications of Cesarean surgery than from normal vaginal birth. More than a dozen operative and post-op complications for the mother are associated with Cesarean including maternal death, maternal brain damage, anesthetic accidents, drug reactions, infection, accidental surgical injury, hemorrhage, emergency hysterectomy, blood clots in the lungs, need to be admitted to ICU, need to be on life support, inability to breastfeed.

Potentially-lethal complications and protracted difficulties extend into the postpartum period, post-cesarean reproduction, post-cesarean pregnancies and post-cesarean labors. Reproduction complications include secondary infertility, miscarriage and tubal pregnancy. Delayed or downstream complications in future pregnancies include placental abruption, placenta previa, placenta percreta, uterine rupture, and maternal death or permanent neurologically impairment.

Risks to babies include accidental premature delivery, surgical injury during the C-section, respiratory distress, increased rates of admission to NICU. Risks to babies in subsequent pregnancies include placenta abruption/stillbirth, death or permanent neurological disability (do to uterine rupture), lung disease and increased rates of both childhood and adult asthma.

For this reason, the reduction in operative deliveries associated with physiological management is an important tool in the reduction of maternal mortality and perinatal loss in future pregnancies. A large number of women with identified pregnancy risks such as VBAC or breech baby at present are totally unable to get appropriate obstetrical care. Some of these women are choosing instead to be cared for by midwives and other are choosing unattended home births. These parental choices may address the family’s own personal dilemma, but it doesn’t address the underlying problem. The major social problem here is a disenfranchised obstetrical profession – doctors forbidden to do doctoring -- and the subsequently run-away costs, both personal and economic. This prevents the United States from having a medically conservative and responsible maternity care system. This is also a handicap in a global economy, which prevents the US from being competitive around the world due to the high cost associated with medicalizing a healthy population of childbearing women and the resulting high Cesarean rate.

The solution lies in three specific areas of reform. One is the need for tort law reform in combination with ACOG policy statements and position papers that recognize physiological management as an appropriate category of care provided by obstetricians to healthy women with normal pregnancies, in which the mother neither desires or requires interventionist obstetrical care.

The second is for medical educators to acknowledge that physiological management is the foremost standard for healthy women worldwide. This would permit them to incorparate the principles of physiology into medical education and subsequently to teach physiological management to medical students and in obstetrical residency programs, with the expectation that physiological principles would be routinely utilized for healthy women.

And last but not least is the staffing of labor and delivery units of hospitals by professional midwives as practitioners who are authorized to provide the full spectrum of physiological care to healthy women. On the continuum of physiological management, the ‘birth’ or ‘delivery’ is not a separate activity requiring the services of a surgical specialist, but rather a normal part of normal maternity care as provided by the hospital-based midwife. At the request of either the mother or the obstetrician, the physician may be called to ‘catch’ the baby, but it would not be required by hospital policy.

Part and parcel to this changed relationship with hospital-based midwifery is also the ‘normalizing’ or rehabilitating of relationships with community-based midwifery, so that complementary professional relationships can develop between community midwives and hospital obstetricians. This would lead to the integration of community midwives into the health care system and result in “relocated home births” for that category of women with significant risk factors that can be reduced by early and easy access to medical services.