What's a "midwife?" Please let the ACNM know.

This week, the birth blogosphere was abuzz with news that the American College of Nurse-Midwives has changed its position statement on midwife certification and its definition of what a midwife is.

Essentially, what it boils down to is that the ACNM will not recognize a midwife unless she has received her academic and clinical training in a formal education program. The North American Registry of Midwives is the national agency which certifies professional midwives. After a midwife has met conceptual learning objectives and gained significant clinical experience with out-of-hospital births and prenatal care, she can become a Certified Professional Midwife. There are a number of formal education programs in which an aspiring midwife can enroll; however, an aspiring midwife can obtain her theoretical and conceptual learning through apprenticeship, under the guidance of wise, experienced and mentoring midwives. It's probably the oldest, most traditional form of learning there is.

There are many paths to learning, and it makes sense that the art of traditional midwifery honors learning through apprenticeship. NARM certification is rigorous; it recognizes different paths to learning, and ensures quality practice and standards of care through its certification process. Additionally, its standards for certification are used by the 26 states that regulate midwifery, states in which CNM's, OB's and CPM's practice collaboratively in a variety of birth locations.

It is curious that in its definition of a midwife, the ACNM wishes to split the midwives certified by NARM into separate camps, legitimizing one and squeezing out the other. It is particularly disheartening in the 24 unregulated states like Massachusetts, where the only opportunity to learn midwifery is through apprenticeship. What gain does the ACNM have in only recognizing some CPM's?

NARM has created a petition asking the ACNM to reconsider its statement and respect the knowledge and diverse training that those who hold the CPM carry. At this writing, the petition has over 1160 signatures. Please take a few moments to sign the petition, taking action to protect birthing choices, which includes access to qualified, trained, experienced Certifed Professional Midwives.

(this has been cross-posted on the Massachusetts Friends of Midwives blog)

MRSA infections at Beth Israel Hospital in Boston

Click the title above, and you'll be linked to an article about infection control at one of Boston's largest hospitals. The hospital was found in serious non-compliance with infection control protocols, resulting in staph and MRSA infections -- in mothers and their newborn babies in the labor, delivery, and maternity units.

I don't wish to bash the BI. Two of my three daughters were born there. I had good experiences there. I hadn't developed an interest yet in midwifery, doulas, and non-medicalized, normal birth; my care there was a good match for what I valued then. As I learned more about birth as a non-medical event, I chose not to return to BI for my 3rd daughter's birth, but I have no regrets about decisions I made in the past.

But the situation, which could probably happen in any hospital in the country, can prompt more discussion about out-of-hospital birth. A healthy woman with a healthy pregnancy who goes into labor spontaneously at term should have the right to a homebirth or non-hospital birth center with a qualified and trained midwife. In the comfort of her own home or in a home-like setting, with the intimacy of loved ones around her, she can move freely through labor, feed herself and drink to thirst as she needs to in order to maintain her strength, and allow her body to engage in the uninterrupted physiological process of childbirth. That kind of normal birth is not medical, so therefore doesn't need a hospital and the whole hospital package -- like infections due to non-compliance of infection control protocol, or medical interventions that are either unwanted or not truly medically necessary, which leads to further interventions, which can then create an emergency. At the risk of sounding prosaic, hospitals are for sick people.

A C-Section rate of 18%???

Click on the title above to read about the amazingly low c-section rate at a New England hospital (woe that it is not in Boston...). The national average is 34%, and the hospital credits the Midwifery Model of Care for its low c-section rate. Let's hear it for midwives!!

High-Tech vs. High-Touch Maternity Care

Please click on the title above to read a simple, straightforward summary about the benefits to keeping interventions low in childbirth, from Consumer Reports -- a fairly benign publication that reaches out to a wide segment of people, not just alternative health or alternative birth populations!

In the Company of Midwives

2AM, January 25 (Sunday)
My 7 year old is sleeping beside me. Last temperature check was 102F. We are both tossing and turning, keeping each other awake. I feel a slight, quick gush in my underwear and go to the bathroom, anxious that my water has broken. But it is blood, bright red like a period, and some of it thick.

My husband is sleeping in the 7 year old's bed, which is downstairs beside the 4 year old's bed. I wake him up to tell him what is happening; he doesn't tell me for a few days that this frightened him.

But I'd seen blood before in this pregnancy. I already knew what came next. Call the midwife on call, go to triage - which is in the hospital, and not the Birth Center where I was aiming to give birth when the time came - be placed on an external fetal monitor for an hour or so, and then go home because the baby is fine, I am fine. The blood is a mystery, but then it goes away. And so it went, just like that. During the whole thing, while waiting for the midwife on call to call me back, while waiting for the cab, while in the cab going to the hospital, I have a contraction or two. Nothing big, nothing regular.

8PM, same day. Same thing.
My dear friend comes to put my kids to bed, and this time my husband comes with me. Bleeding stops, the baby is fine, fine, fine; the midwife on call acknowledges the continuing mystery, cautions me with specific instructions on when to return, then says I can go home. We are heading out the door, jackets on, when the attending OB says no. She says I should stay overnight for continuous fetal monitoring, but adds "If I could make you do what I really want you to do, I'd induce you now." She says, despite the baby being fine, despite my not having any pain, despite the bleeding which has again stopped, despite the absence of any immediate certain problem, "What's the point in being pregnant anymore? You are already full-term." I know if I stay, even if the baby continues to be fine throughout the night, that in the morning I will be faced with induction. She says if I insist on going home, I must sign a waiver that I have signed out Against Medical Advice.

The problem she is concerned about - that the midwives and I and she are all concerned about - is that my placenta is abrupting. The midwives have cared for me with due diligence. And even though it cannot be ruled out with 100% certainty, this would be an atypical presentation of abruption. I am a good patient; I follow instructions well, and I am not unreasonable. I just want to go home and let labor start on its own, and I know it will soon. The OB states frankly that I'm probably not abrupting, but because she cannot guarantee it, she'd rather keep me close by. She states that sometimes if abruption happens it maybe can happen really quickly. I appreciate that she wants to keep me safe, but I also feel that in the absence of any other symptoms, normal birth prevails. She is pretty and young with eyeglasses that are trendy but not so funky as to undermine her authority. She says "You're also over 35. Statistically you are at high risk for many problems."

I sign out AMA.

1AM, January 26 (Monday)
Bleeding again. I am a good patient; I follow instructions well, and I am not unreasonable. I return to the hospital and settle in for the night, fetal monitors belted to my belly. I know I will not be leaving this hospital again, not with this baby still inside my body. I know I will be induced by morning.

8:30AM, same day
It is a new morning. I never hear from the OB again, but the shifts have changed, and now my midwife is on duty. She sits beside me and holds my hand to tell me gently that she's sorry, but I can't give birth at the Birth Center anymore. It's easy to let that go, as my big concern is with induction. I am having contractions, but if they come regularly, they are mild and barely a distraction. Conversely, if they are strong and require my full attention, they last only 30 seconds. Meanwhile, the bleeding has not subsided like it has every time before. In fact, though it is not a hemorrhage, perhaps it is even slightly increasing.

My midwife explains the reasons why induction is warranted, and I believe her, not only because she has seen me more than a dozen times through the course of this normal and healthy pregnancy, but because she is presenting me with induction options. She has not dictated my care, then placed orders with a nurse and disappeared. She has remained sitting beside my bed and holding my hand, and she explains each choice to me, knowing what my hopes and preferences have been for this labor. In fact, when my husband walks in to the room, she explains it all a second time, for his benefit. Contractions are still coming, but they remain inconsistent. So we choose a course of action together, my midwife, husband, and I, one that will allow me to have as normal a birth as possible.

11AM, same day
Somehow, I missed breakfast. I cannot go into labor on an empty stomach, and clear fluids certainly will not sustain me through the workout that is childbirth. My midwife orders me a lunch. She takes heat from the Attending OB. "She's not in active labor," she tells him, which is the hospital policy. "She's not in any labor at all, and she's hungry."

12:30PM, same day
There is a delay in the induction. Pharmacy hasn't delivered the drugs yet, and there are some patients in triage who need evaluation. I eat - plentifully. I put my fork down, push the tray away, and suddenly a force wraps itself around my mid-section. I close my eyes and breathe through it, and it keeps on going. A minute and a half goes by before the contraction lets go of me. The room is suddenly as hot as July, and I feel another one coming. I stand up, hold on to my husband, let my knees go weak and try to relax every single muscle in my body so that my uterus is the only muscle efforting. Another minute and a half goes by. My eyes are closed, and I hear my midwife enter the room. There is a small space between the surges of contractions, and just as I feel another one coming upon me, she says it. She says it for me, because the contractions have taken all my breath, and I can no longer talk. She says, "You're in labor, Maria. Let's cancel that induction. This is all you."

Same day, some time after 12:30PM and before 1:47PM
I take my face away from where I have buried it in my husband's neck, regain my stance and say calmly "I can do this," while catching my breath. My husband holds me and tightens his arms around me, telling me silently that he believes me. I hear my midwife's affirmation, "You can do this, Maria."

1:47PM, January 26 (Monday)
My daughter is born. Official time from start of labor to birth is 1 hour and 17 minutes. She is caught by my midwife, who later writes in the chart:
NSVD
It stands for Normal Spontaneous Vaginal Delivery.