Birth activists were all pretty happy this week reading about the new U.K. National Health Service NICE guidelines recommending birth at home with a midwife, or in a midwife-unit for first-time mothers. (And again when seeing the ripple headlines here and here and here.)
"The UK gets it right," we posted on The Big Push for Midwives Campaign Facebook page. But, positive as this development may be, it is clear it will take far more than British sanity about birth for US policymakers or the US maternity care system to likewise "get it right" or even to "get it."
As one commenter quickly noted, opponents will quickly hog-tie the new UK policy to British midwifery education, or the integration of home and hospital in that country ... the usual rhetorical smoke-and-mirror tricks used to deflect attention from the fact that US home birth midwives, CPMs, are experts in out-of-hospital care, the gold standard, educated specifically to excel as providers of home and other out-of-hospital maternity care. The casual reader, who does not yet know those facts about CPMs, will then fail to realize that the NICE recommendations hold true also for American women who, like their British sisters, are female mammals (smoke and mirrors be damned).
The good news is that The New York Times journalists saw instantly the real basis for the differences in care between the US and the UK. Read it here. Notice, in the 11th paragraph, right after the obligatory recitation of ACOG's standard rote objection to home birth ("we do not believe" home birth is safe), the article points out:
"If such a recommendation were made in the United States, doctors might worry about losing patients to midwives."
There it is, folks, in a nutshell, laid right out in the open.
The New York Times gets it, it understands that ACOG's opposition to home birth isn't really about safety, or education, or models or care, or liking CNMs better. It is all about competition, losing patients to another type of provider, about money. '
The article continues: "That concern is absent in Britain's taxpayer-funded system. There are no financial incentives in the U.K. for doctors to deliver in a particular setting (that is, hospitals) because there is no personal gain."
Shazam. It is thrilling to read that in (news) print! Yes, the percentage of home births in the US is relatively low, but for heaven's sake, it increased by 29% from 1990 to 2009, and it has continued to rise in an upward trajectory. Consumer choice is a powerful thing.
'ACOG and the hospitals can read these reports too, and they understand the implications for their bottom lines. When MacDorman, Mathews, and Declercq write, in their 2014 Data Brief on 2012 place-of-birth data exactly what those implications are: "If this increase continues, it has the potential to affect facility usage, clinician training, as well as resource allocation," the OBs and hospitals know what is being written on the wall – and we do too.
Add to that the intriguing responses regarding future birth sites provided by the representative sample of women who had given birth in a hospital in 2012-2013 and who responded to Childbirth Connection's 2013 Listening to Mothers III: New Mothers Speak Out Surveys and Reports. Asked how open she might be to a future birth at home, an amazing 11% indicated that they would definitely want to give birth at home, while another 18% said they would consider a home birth. Likewise, 25% of survey participants would definitely want to use a freestanding birth center! Another 39% said they would consider a birth center.
This is huge, friends.
At the present time, the statistics gathered and published by Childbirth Connection reveal that, in 2012, 23% of all hospitalizations were for childbirth and newborn care, and that maternity care is the "single most common" cause for hospitalization in the US.
So, if one owned a hospital, or if one medically managed all of one's patient deliveries at a hospital, how would one feel about handing off 10% or 25% of those families to midwives and birth centers? And not in some distant 20-years-from-now future, but as soon as those Mothers stop speaking out long enough to get pregnant again? Well, if present-day monopolies are any indicator, one would fight tooth and nail to maintain one's market share of the $111 billion one billed for maternity care facility charges alone in 2010.
"First they ignore you, then they laugh at you, then they fight you, then you win."
Many birth activists understand that the out-of-hospital birth movement in the US is in the next-to-last stage of this lifecycle. "They" are fighting against sanity, reality, and consumer choice. Hard. And when their junk science isn't sticking, they are trotting out the bigwigs at ACNM and ACOG shouting that CPMs need more education in more structured institutions, because those bigwigs have a very long history of taking away existing traditional educational paths and intentionally closing off and slowing down production of their competition (King Bigwig himself Abraham Flexner did it exceedingly well in 1914).
Sadly, it gets even worse when "they" sense the ship isn't sailing solely in their $111 billion direction. Bigwigs like those of Delaware ACOG come out from the bowels of the boat with last-ditch, cut-throat tactics to snatch away legislative victory from mothers and families fighting for increased access to CPMs and more out-of-hospital birth options. And when they slink back below deck, Lady Justice rightly asks why do "they" do it? Are "they" truly concerned for patient safety, or only about throwing all the midwife competitors overboard (or nearly as bad, down into the physician-oversight slave galleys)?
As the Listening to Mothers III: New Mothers Speak Out and the latest CDC Data Brief tell the story, The Big Push for Midwives Campaign (and the whole PushNation) is getting the message across. Women are hearing the true facts, and informing and educating themselves. They are beginning to make new choices.
Dearest birth activists, amazing Pushers, and Salty Dogs, we are all seaworthy!
Don't give up the fight now and don't reach uncomfortable compromises.
Do not even be discouraged, all hands on deck!
We are in the fighting stage to turn this battleship around, and the data point toward the absolute bearing of our winning.
The federal Centers for Medicare and Medicaid Services (CMS) released on April 9 the Medicare billing information for physician providers after decades of litigation by the American Medical Association (AMA) seeking to block the release. [http://www.reuters.com/article/2014/04/09/us-usa-medicare-data-idUSBREA3809H20140409] Some of the dollar figures for federal moneys paid to individual physicians have been shocking, but those of us who have studied the economics of maternity care should not be surprised. It is basic economics that markets in which consumer access to information is blocked, and also where real competition has been suppressed, will be characterized by high prices.
The Big Push for Midwives Campaign supports the release of provider billing information because it benefits women and their families. Consumers should have access to information that could affect decisions about their healthcare, including the choice of provider and the cost of a provider's services. An informed public is better equipped to exercise not only health care choices, but also political speech, especially now that private health plans are required to provide maternity coverage. This kind of data educates both citizens and policymakers about the direct and indirect costs related to healthcare and allows better informed decision making.
Why did the AMA fight to suppress this information for so long? The assumption that consumers are ignorant and need to be protected from information goes back to early American court cases from the 1700s. Back then even physicians did not understand what diseases were and how they spread. Most people could not read and had very limited education. Even if they could read, the information was stuck in books in far-off universities. This remained true even during much of the last century.
Today, most people can read and have access medical and health care information on the internet. They could have had access to this cost-related information if the AMA had not impeded access. Women and their families should have access to whatever information they need that could affect their health care decisions, including relative costs, so they can make intelligent decisions based on the evidence.
The heart of midwifery is educating women and their families so that they make informed decisions instead of keeping them ignorant and dependent on providers. Releasing information like this is a good first step. We need to make this information user-friendly and to educate both citizens and policymakers to compare many factors – costs, outcomes, consumer satisfaction – so they can understand and use the information effectively. Consumers need this information for health care decision, and policy makers should be looking at and comparing what the federal government pays for physician services versus the services of other health professionals, such as midwives.
For those playing along at home, as soon as The Big Push for Midwives announced the "Largest US Study to Date Finds Home Birth to Be a Safe Option for Most Women" based on newly released research (here and here), Big Medicine played a card from its dark deck.
Goliath reached up its sleeve to flip the Ace of Scaremongering at millions of mothers, families, and babies across the US, in its desperate attempt to try to shut/shout down the truth, citing numbers that are neither published nor peer reviewed, and based on birth certificate data.
The good news is that the truth about the safety of out-of-hospital birth as published in the Journal of Midwifery & Women's Health is still available even if Goliath is teetering from the stone that hit his exposed forehead.
While it is beyond pathetic to see the turf war that Big Medicine continues is waging, it is sadly not surprising. Goliath doesn't seem to care that:
- Rural, uninsured, and underinsured women need more maternity care options.
- States need to remove barriers that deny mothers, families, and babies access to high-quality, safe, and cost-effective midwifery care.
- The US needs to get it in gear to significantly reduce rates of prematurity and low-birth weigh that are critical to reducing racial and economic disparities in birth outcomes, and reducing unnecessary costs to our health care system.
- The US has one of the highest rates of both infant and maternal death among industrialized countries, and frankly, the US maternity care system is broken. Maternal and fetal mortality rates are worse than 40 other countries worldwide, and we spend more money than anyone else on maternity care. Where is almost all that care being delivered? The answer Goliath doesn't want you to see through his 30%-c-section-tinted glasses is HOSPITALS.
Big Medicine is NOT doing so great at birth in America, and Big Medicine's problem with out-of-hospital birth is not that it isn't safe. Rather, it's that it is a safe option for most women and thus presents a threat to the Big Medicine status quo and the trade associations and state medical societies who control it. Goliath is deeply dependent on maintaining the status quo … so dependent that Big Medicine will sometimes tell bald-faced lies about out-of-hospital birth research on national television and in other media outlets and hope that no one notices. Here are some other sensible voices on the matter:
- Here's an impressive statement from the American College of Nurse Midwives (ACNM)
- Here's a piece where Missy Cheyney refutes these new scaremongering numbers.
- Here's an item that points out more on the flaws in birth certificate data.
- Here's the response of the Reddit community to a recent diatribe from Big Medicine's biggest shill.
- Here's a commentary by sociologist Barbara Katz Rothman on "Home Birth In a Risk Society."
- Here's a Facebook post by Rebecca Dekker, PhD, RN, APRN of EvidenceBasedBirth.com.
- Here's a Throwback Thursday treat by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery in Science & Sensibility.
- Here's another Throwback Thursday treat by Miriam Pérez of radicaldoula.com published in RH Reality Check.
Here at The Big Push for Midwives, we are ALL IN to knocking Goliath down. The powerful and strong are not always what they seem. David had only a stone and a slingshot to bring down the greatest warrior of his time. The Big Push has only the truth, courage, faith, and the amazing grassroots uprising of the PushStates who fight the good fight every day from where they are with what they have. To see more on these dueling studies, visit the PushHeadlines page today.
Submit your question to the Big Push.
QUESTION #4: Home birth legislation seems to be a true non-partisan issue, with Republicans politicians showing support from the right, as well as feminists from the left. Has this been the experience of the Big Push? Is there any instance from state to state that the Big Push knows of where pro-midwife legislation has been split legislators along party lines?
ANSWER: In every state the support for CPM legislation has been roughly 50/50 between Republicans and Democrats—in fact, another comment we frequently hear is how unusual our list of co-sponsors is and how they've never seen certain far right and far left legislators on the same bill together. And that is one of our primary strengths as a movement, that supporting access to out-of-hospital maternity care and midwives who are specially trained to provide it is naturally bipartisan.
In fact, the only people who oppose expanding maternity care options and choices are the special interest groups with a financial stake in maintaining and the legislators who are beholden to them.
What's inspiring about our movement, though, is that we're such a refreshing example of how politics is supposed to work. Many of the legislators we try to recruit have been "bought" by medical industry money, but if enough of their constituents speak up, votes often trump special interest money. And we're able to mobilize a significant number of voters in every state, not only via outreach to legislators and staff, but also through the campaign work we do in support of our friends and, sometimes, against our opponents. Midwifery supporters in a number of states have played a significant role in influencing the outcome of state legislative races—in Wisconsin, we even mobilized the Amish to turn out and vote.
Submit your question to the Big Push.
QUESTION #3: What type of opposition have you encountered during your work for the Big Push? Can you note a prominent incident or situation?
ANSWER: In virtually every state we generate fierce opposition from professional associations, such as ACOG and state medical societies, with a vested financial interest in maintaining what amounts to a near monopoly on the provision of maternity care in the U.S. Opponent groups, of course, deny that their objections to legislation authorizing Certified Professional Midwives to practice has anything to do with money or turf because out-of-hospital birth represents such a small corner of the maternity care market.
But what they aren’t saying is that out-of-hospital maternity care is a market that is poised for growth and has, in fact, been growing at a noticeable pace since the economic downturn began. As more families are losing their health insurance and as more women are finding the high-cost of maternity care riders and deductibles to be beyond their means, more women are seeking out alternatives to hospital-based maternity care. And this is another reason why our media outreach efforts have been so successful—more women are learning that about those alternatives.
Certified Professional Midwives all over the country are reporting unprecedented demand for their services, and a North Carolina study recently found a 50 percent increase in the demand over the course of one year alone. No single incident stands out, but we have noticed an interesting pattern in many states. Early on in the process, the legislators who support us expect to have an easy road ahead of them and often think we're exaggerating when we tell them how strong the opposition to our bill is going to be, since they consider our issue to be a pretty small one, a no-brainer that will sail right through both houses in no time.
But once they see the unusual procedural roadblocks that typically get thrown our way, the unorthodox committee assignments used to try to kill our bills, and the extreme level of "dirty" politicking that we typically have to overcome, the comment we hear over and over is, "Wow—I have never seen that happen before in all my years in the statehouse." We can’t tell you how many times we’ve heard comments to that effect from legislators who are shocked by how opponent groups will stop at nothing to kill CPM legislation, often employing desperate and heavy-handed tactics.
Submit your question to the Big Push.
QUESTION #1: The American Medical Association (AMA) (along with other doctor trade organizations) has taken a stance diametrically opposed to home birth and Certified Professional Midwives (CPMs). Activist midwives and consumers who are involved in statewide legislative efforts across the US have cited the AMA's stance as a main motivator in their activism: they want to get legislation passed before the anti home birth lobby can. To what degree is the Big Push for Midwives a reaction to the stance of the AMA and other doctor's groups at the state and national levels?
ANSWER: When it comes to Resolutions the AMA passes in opposition to home birth, these are adopted in response to the growing success of the grassroots movement in support of expanding access to Certified Professional Midwives and out-of-hospital maternity care. Since midwifery activists began organizing across states in 2005—an effort that culminated in the launch of the Big Push for Midwives Campaign in 2007—UT, VA, WI, MO, ME, ID, and IN passed laws authorizing legal practice for Certified Professional Midwives, while bills that had been effectively dead for many years in states such as IL, NC, MA, AL, SD, and AL suddenly began to make significant progress.
Once such item, Resolution 205, was brought to the AMA on behalf of the American College of Obstetricians and Gynecologists (ACOG), which had issued alerts to its members about the Big Push’s legislative successes and the need to increase the resources dedicated to fighting CPM legislation (these alerts are titled "ACOG 2007 Midwifery Year In Review" and "ACOG 2008 Midwifery Year In Review").
So clearly they are concerned about the progress we’ve been making and they've made defeating our bills their second most urgent state legislative priority, ahead of issues such as medical liability reform, access to contraception, and reducing perinatal HIV.
Another such item, Resolution 814, sought to limit the scope of practice for allied health care providers, though it predates the Big Push and doesn't specifically mention Certified Professional Midwives (which physician groups love to try to malign by using the oxymoron, "lay midwives"), it was brought to the table by the Texas Association of Anesthesiologists, which had fought quite forcefully, though unsuccessfully, to repeal their state law authorizing CPMs to practice. (If you're interested in learning more about that battle, we can put you in touch with the lobbyist who helped the Texas midwives defeat the TAA, but it’s a safe bet that it was one of the primary catalysts for Resolution 814.)
At its November 2005 Interim Meeting, the American Medical Association (AMA) House of Delegates adopted Resolution 814 titled, “Limited Licensure Health Care Provider Training and Certification Standards.” The resolution states:
RESOLVED, That our AMA, through the Scope of Practice Partnership, immediately embark on a campaign to identify and have elected or appointed to state medical boards physicians (MDs or DOs) who are committed to asserting and exercising their full authority to regulate the practice of medicine by all persons within a state notwithstanding efforts by boards of nursing or other entities that seek to unilaterally redefine their scope of practice into areas that are true medical practice. (Directive to Take Action)
Resolution 814 emerged from the Scope of Practice Partnership (SOPP), which was formed by the leadership of the AMA and other physician trade organizations to obstruct expansion and to restrict the licensed scope of practice of other healthcare professionals. These actions by organized medicine limit access to providers who have the education, expertise and experience to offer safe, quality health care services to the public, particularly for rural, uninsured and other underserved populations.
The Big Push for Midwives Campaign objects to the misleading and divisive language used in the AMA SOPP resolution, which needlessly pits medical doctors against other healthcare professionals at a time when the American public is faced with unprecedented healthcare shortages and millions of uninsured children and adults. The healthcare professionals that have been targeted by SOPP, which include nurse practitioners, physician assistants, podiatrists, optometrists, psychologists, chiropractors, and midwives, are the solution to this crisis, not the problem. The erroneous claim that SOPP can or should determine what is best for the patients of other healthcare professionals represents an outdated and patronizing line of thinking that cannot possibly serve the needs of today's patients—particularly childbearing women and their babies. Therefore, The Big Push for Midwives opposes SOPP and its efforts to restrict the scope of practice of our allied healthcare partners and to obstruct legislative initiatives that would increase access to licensed Certified Professional Midwives.
Father Knows Best Meets Big Brother Is Watching:
"The SOPP also is overseeing the completion of the AMA Scope of Practice Data Series, a compendium of information and resources for medical associations on 10 non-physician providers, and the creation of a geographic mapping tool that will allow Federation partners the ability to map, on a state-by-state basis and by specialty, the practice location of not only allopathic and osteopathic physicians but also various non-physician providers."
"From the President" by Ronald M. Davis, MD http://elephantcircle.net/?p=429
Following this AMA directive, several state medical boards have targeted more than a dozen midwives in states where CPM licensure is not yet available, leaving hundreds of pregnant women without care.
Have you ever stopped to think about how one group's version of what is true and what isn't becomes the dominant voice? All through history, one group or another has decided that it had the insider information not only about God but about life, the world, how things were supposed to work. If you weren't part of the in-group, if you doubted their worldview, their claims to orthodoxy, you were a heretic and life could get pretty unpleasant if the orthodox view had the support of the government. So, pagans against early Christians, Christians against pagans, Christianity against Islam, Islam against Christianity, Catholics against Protestants -- and that's just Europe and colonial America. Almost every religion was oppressed somewhere at some time and, if it became dominant, has done some oppressing itself.
A state-forced orthodox worldview can lead a lot of people to embrace a belief which, empirically, turns out to be false. But those "heretics" who saw the flaws in the worldview, those who are the ones who said "you know, by my scientific calculations, the earth is probably round," and, in addition, "it revolves around the sun." They got into a lot of trouble when the state- or religion-enforced world view saw a flat earth that was the center of the universe.
When finding ways to make sure that Consumers can access the provider of their choice so that they can have a safe birth in the location of their choice, you inevitably run into the dominant worldview of the American Medical Association (AMA). To wit, in 1914, a man named Abraham Flexner told the AMA to get in one room, agree on what teaching was right, and then lobby the State and Federal governments to enforce this with their power. He didn't use the word "orthodoxy," but it just means "right teaching." All of the AMA's justification for dominance comes from the idea that they are "orthodox," and the best plan is to have the state force their ideas on us "heretics."
We now mock some of the pre-enlightenment ideas of the Church, such as the "flat earth" theory, but we aren't really any better. We still let orthodoxy dictate healthcare decisions instead of the evidence. For example, physicians knew for 20 years that they should not x-ray pregnant women, but it was "standard of care" i.e. "orthodoxy." So they kept on doing it until forced to stop.
Our challenge is very simple but very difficult: No matter what we say or can prove, "they" are going to state an unwavering belief in a flat earth. "There be monsters over there!" "You are going to sail off the end of the world!" Our task is to get us the freedom to risk sailing that way anyway on the chance that we might discover a new world instead.
Fortunately, we've already done the math. The world is, indeed, round.
Special thanks to Keith Williston of Missouri for inspiring this PushBlog post. At the heart of Keith's work in the PushStates, in Missouri and beyond, is his family-owned freestanding birth center, A Mother's Love Birth Center. Keith and his wife Rachel Williston, CNM, CPM, encourage more people to become involved in the work of the PushStates.