The Big Push for Midwives

On Mon, Dec 8, 2014 at 5:31 PM, PushGirl #2,135 wrote:

"This study–published in Pediatrics Jan 2015–looked at 2 million kids, and found that children delivered by cesarean delivery had significantly increased risk of asthma, systemic connective tissue disorders, juvenile arthritis, inflammatory bowel disease, immune deficiencies, and leukemia.

"I’d call that some evidence."

On Tue, Dec 9, 2014 at 6:52 PM, PushGirl #4,933 wrote:

"Why isn't this in the news...?"

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."  

~Mahatma Ghandi

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.

Congratulations from the Big Push for Midwives Campaign to the Friends of Missouri Midwives (FOMM) and the Missouri Midwives Association (MMA) on the fifth anniversary of the Missouri Supreme Court decision!

The Big Push for Midwives steering committee particularly LOVES this latest FOMM news release as our own Susan Jenkins was one of the attorneys who wrote the birth activists' amicus brief back then and consulted with MMA leadership on the text of the bill.

Please enjoy the news release here, which is well-written, upbeat, and positive. Again, congratulations to Missouri!!

Resulting PushHeadlines:

• Missourinet  |  July 9, 2013

Members of the Big Push for Midwives Campaign applaud the publication of the American Association of Birth Centers' landmark National Birth Center Study II in the Journal of Midwifery & Women’s Health.

The national prospective study pointed to excellent outcomes in midwife-led birth centers run by both Certified Professional Midwives and Certified Nurse-Midwives. Seventy-nine birth centers participated in the study, recording data for more than 15,000 prenatal courses and births. For more information and insights, check out the blog posts and alerts from Childbirth Connection, Citizens for Midwifery, Lamaze International's Science and Sensibility and many others about the study.

While it wasn’t intended as a direct comparison of CPM and CNM outcomes in birth centers, the study nevertheless provides solid evidence that the excellent outcomes achieved in these birth centers occurred regardless of whether a CNM, a CPM, or a joint team of both provided the midwifery care. At the same time the study, which was published in a scientific peer-reviewed journal, shows that outcomes are not dependent upon any one particular midwifery certification program or any particular educational pathway to certification.

The Big Push calls on policy makers to focus on the demographics of the more than 15,000 women who participated in the study. The majority of birth center consumers were middle-class white women, confirming the unfortunate reality that women of color and low-income women are much less likely to take advantage of the out-of-hospital birth options that produce such excellent outcomes.

Increasing access to birth centers through section 2301 of the Affordable Care Act, which added birth centers and midwifery care in birth centers as mandatory Medicaid services, as well as access to home birth through federal legislation that would guarantee CPMs as providers of a mandated Medicaid service, are necessary steps to making the midwives model care in both settings accessible to all women.

The first step needs to be continued pushing for licensing for CPMs, the specialists in out-of-hospital maternity care, to legally practice in all fifty states. Unless they are licensed by their state, CPMs cannot be included in Medicaid, Tricare, and other government programs – including the new health insurance exchanges under the Affordable Care Act – that will make midwifery care accessible to all women. This new study should go far to convince state legislators to license midwives and federal policymakers to include CPMs in these payment systems and other federal health care programs.

We are keeping the focus on what really matters, after all – delivering the kind of excellent woman-centered care highlighted in this study to the women to want and need it.

Shannon Earle holds her new baby Kiera Breen Earle, moments after she was born at their home. (Amanda Steen / NPR)

PushNews from The Big Push for Midwives Campaign

CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: January 26, 2012

CDC Finds Continued Increase in Home Births - Report Highlights Disparities in Access for Women of Color

WASHINGTON, D.C. (January 26, 2012)—A report released by the CDC today found a 29 percent increase in home births from 2004 to 2009. The rate of home births among non-Hispanic white women underwent a dramatic increase, while the rate for women of color decreased or remained stagnant, a trend that reflects racial and ethnic disparities in other areas of maternity care throughout the U.S.

"Unfortunately, the women who could most benefit from out-of-hospital midwifery care are those who are least likely to have access to Certified Professional Midwives with the specialized training needed to provide it," said Susan Jenkins, Legal Counsel for The Big Push for Midwives Campaign. "The CDC report and other research shows that babies born to women cared for by Certified Professional Midwives are far less likely to be preterm or low birth weight, two of the primary contributing factors not only to infant mortality, but to racial and ethnic disparities in birth outcomes."

Barriers to out-of-hospital maternity care include laws in 23 states, the District of Columbia, and Puerto Rico that prohibit Certified Professional Midwives from practicing, as well as laws or policies in all but 11 of the remaining states that deny Medicaid coverage for home births managed by Certified Professional Midwives.

"As we work to address disparities by increasing the cultural proficiency of midwives practicing in out-of-hospital settings and diversifying the midwifery work force, we also need to change laws nationwide so that all women have access to out-of-hospital maternity care with Certified Professional Midwives," said Jenkins. The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the U.S. who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org
CDC report: http://www.cdc.gov/nchs/data/databriefs/db84.pdf
NPR All Things Considered story  |  Jan 26, 2012

####

PushNews from The Big Push for Midwives Campaign
CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: August 15, 2011

Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science

Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence

WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of "good and consistent scientific evidence." The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on "limited or inconsistent evidence" and on "expert opinion," both of which are known to be inadequate predictors of safety or efficacy.

"The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform," said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. "As the authors of the study remind us, guidelines are only as good as the evidence that supports them."

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with "suspected" large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

"It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers," said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. "ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies."

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

####

(FULL STUDY is available in PDF format on this page)