Wednesday, December 23, 2009

Midwife Connection Goes on Vacation

Midwife Connection is taking a holiday break. Season’s Greetings and best wishes for a happy, healthy, and prosperous New Year from your friends at the American College of Nurse-Midwives.

Thursday, December 17, 2009

What Do CNMs/CMs Think about Planned Homebirth?

by Eileen Ehudin Beard, CNM, FNP

An interesting study in the December issue of Birth explores American nurse-midwives’ attitudes toward planned homebirth and their impact on a woman’s choice of birth site. The findings suggest that, as a group, nurse-midwives have a “moderately favorable” attitude about planned homebirth and that their education and practice experiences may greatly influence their patients’ maternity care choices.

Factors that positively influenced nurse-midwives’ attitudes were clinical and educational experiences with planned homebirth, exposure to planned homebirth, and younger age. The study also identified barriers that had a negative impact on attitudes toward planned homebirth, including financial and time constraints, inability to access medical consultation, and fear of peer censure.

As health care providers, we sometimes underestimate the influence we have on women. When I was seeing patients at the Baltimore Birth Center, I was acutely aware of how my opinion could influence a patient’s choices. The way I presented out-of-hospital birth to my patients was a big factor in their decisions. Of course, my goal was to educate patients and assist them in the decision-making process. I always wanted women and their families to make the choice that was best for them. But when I read the study in Birth, it made me revisit the issue of the attitudes we have and whether we are objective in the information that we present to women. When I was primarily working at the birth center, I don’t ever remember offering the option of homebirth unless the woman specifically requested information. Was I doing my patients and their families a disservice?

It’s worth noting that many certified nurse-midwives (CNMs) and certified midwives (CMs) have a strongly favorable attitude toward planned homebirth. According to CDC data, CNMs/CMs attended nearly 4,000 homebirths in 2006. But as a group, we have some work to do to decrease the barriers to homebirth practice and to seriously examine our personal views. If we are not comfortable with out-of-hospital birth, our patients will not view it as a viable option. And true informed choice cannot happen if a woman is not aware of all her options.

Wednesday, December 16, 2009

Do You Match with a Midwife?

by Melissa Garvey, ACNM Writer and Editor

Have you ever taken one of those online quizzes that matches you with the political candidate who most shares your views? So many people are surprised to find they match with a political candidate they never considered. It’s easy to cast a vote in favor of the candidate who gets the seal of approval from family members, friends, or the media rather than to objectively evaluate your beliefs and the candidate’s stances. Unfortunately, many women choose their birth care provider in the same manner.

That’s why I’m thrilled about a new online quiz that helps women objectively evaluate the type of care provider who will best meet their needs. Created by ACNM and Jones Public Affairs, Inc. and funded by the A.C.N.M. Foundation, Inc., the quiz was in development for more than a year and has passed the careful scrutiny of a panel of maternity care experts. This is more than your average purely-entertainment-factor online quiz.

The name of the URL that hosts the quiz,, was chosen to appeal to a broad range of childbearing-aged women (hat-tip to ACNM Graphics Designer Simone Christian!). Our hope is that millions of women will take the quiz and be surprised to find they match with a midwife. Here are some ways you can help spread the word:
  • Post the link on your website or blog.
  • Share the link on your social networking profiles, including Facebook, Twitter, and any other site where you’re active.
  • Take the quiz at and if you’re impressed with your experience, consider writing your own blog post about it.
For more information about the quiz, check out the ACNM news release that went out this morning.

Thursday, December 10, 2009

A Few of My Favorite Comments

by Melissa Garvey, ACNM Writer and Editor

Comments are what make a blog come to life. A blog without comments is no different than a magazine article, an online newsletter, or a plain old webpage. That’s why every comment we receive at Midwife Connection puts a smile on my face. Long, short, positive, negative—I love them all. Here are a few of my favorites.

About Should a Pharmacist be Able to Refuse to Fill a Prescription?

“But to the pharmacists in question, it is forcing them to participate in the murder of another human. Which should not be forced on anybody.”

“I agree with you, Amie. I cannot understand asking an individual to drive across town, to another town, to another county, etc... to have access to birth control.”

About What Mammography and Continuous Electronic Fetal Heart Rate Monitoring Have in Common

“My mom died from a VERY aggressive breast cancer at 47 yrs old. She was diagnosed at 42. Cancer is not akin to low risk pregnancy. I think women should start screenings in their 30's.”

About It’s Time to Fight for Preemies

“My son was born at 34 weeks, suffered from undetected chronic brain bleeds, and will now never live completely independent. I get tired of the blase attitude towards these late preemies (34-37wks). They are likely to do better but bad things can still happen.”

About BJOG Study Finds Homebirth as Safe as Hospital Birth

“What an elegant study! And unsurprising conclusion. It will be nice when practice begins to catch up with the evidence. Thank you for posting this midwife-friendly piece.”
-home birth CNM

Wondering what makes a good blog comment? Try listening to Grammar Girl’s How to Write a Great Blog Comment.

Tuesday, December 8, 2009

Should a pharmacist be able to refuse to fill a prescription?

by Heather Bradford, CNM, ARNP
Chair, ACNM Government Affairs Committee

Here in WA State, a prescription refusal issue is working its way through the legal system. Many people are calling it “Refuse and Refer” claiming that it is appropriate for a pharmacy or a pharmacist to refuse to fill prescriptions to which they object on religious or moral grounds, and refer clients elsewhere. A few claim they should be able to refuse with no responsibility to refer at all.

A bit of history: In 2007, at the urging of Governor Christine Gregoire, the WA State Board of Pharmacy adopted two sets of rules governing pharmacy and pharmacist responsibilities to protect patients’ access to lawful prescription medications. Under these rules, a pharmacy can accommodate a pharmacist who objects to dispensing a medication as long as the pharmacy ensures the prescription is filled at that pharmacy in a reasonably timely manner.

Soon thereafter, two pharmacists and a pharmacy challenged these rules, arguing that that filling prescriptions with which they morally disagree violates their constitutional rights. Specifically, the issue was Plan B, as they considered it an abortion-producing drug. However, there are many other drugs that need to be filled in a timely manner, and whose efficacy (and therefore the patient’s health) is compromised by delay, such as drugs treating mental health and HIV.

One could also argue – how is this any different than health care providers being restrained in their practice to follow certain rules? If I am not an advocate of circumcision, should I be required to perform it?

Ultimately, however, I believe this is an access to care issue. I realize that for these pharmacists, it is a religious issue. But should a woman have to drive an extra 50 miles to get her Plan B? Can she afford the extra cost of gas? Will the next pharmacy be open? Will there be another pharmacist who objects there? Will she have an unwanted pregnancy that could have been avoided had the prescription been filled at the objecting pharmacy?

Note: A special thanks to Ann Darlington, CNM, from Seattle for following this issue closely and for keeping us WA State midwives aware and at “the table” of this hot topic discussion.

Thursday, December 3, 2009

Cherrypicking stats: bad form and not helpful

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

Science & Sensibility contributor, Andrea Lythgoe, has a great post up at her own blog. In The Doula Numbers Game, Andrea shows that many of us may be overestimating – and overstating – the beneficial effects of continuous support from doulas. She argues and I agree that using outdated statistics that yield “better” results could compromise our integrity. Moreover, doing so is not necessary to advocate for greater access to doulas.

Data from the Cochrane Systematic Review show more modest effects of doula support, but they still add up to “clinically significant” benefits, greater satisfacation, and no evidence of harm. Maternal-fetal medicine researchers who evaluated the evidence for a variety of obstetric interventions in the November 2008 issue of the American Journal of Obstetrics and Gynecology called doula support “one of the most effective interventions” (p. 446) for improving outcomes. And they did so without being wowed by the inflated early statistics. (They stuck to the Cochrane.)

It can be extremely difficult to look at research objectively. It is human nature to want to cherrypick the research that furthers our cause the most. We may try to find fault with statistics we don’t like and subconsciously ignore problems or limitations of statistics we do. But improving the safety and effectiveness of maternity care requires that we critically analyze the research, which means recognizing limitations and flaws in the studies we agree with and standing behind solid research even when we don’t like the conclusions. We need not worry. Even with a critical lens, research points to a need to radically reform our system to make it more mother-friendly.

Andrea finishes each post in her Understanding Research series with a familiar plea to practice, practice, practice finding and reading research literature. One of the skills we all should practice is to read the studies that seem to contradict our beliefs or biases. Often, these studies are flawed, and spending time reading them helps us hone our ability to spot methodological problems and logical inconsistencies in other research. Other times the research is valid, and we see circumstances where technology and medicine do in fact improve outcomes. Reading these studies can also shed light on important unanswered research questions.

I highly recommend that readers take a look at Andrea’s post for an example of thoughtful critical analysis of statistics on doula support in labor. It is hard to update our long-held beliefs or alter the ways we teach and practice. But this is just what we’re asking of our “medical model” counterparts. We should lead by example.

Tuesday, December 1, 2009

How Many Preemies Does it Take?

by Melissa Avery, CNM, PhD, ACNM President

As National Prematurity Awareness Month closes, we’re digesting a lot of statistics. Today, in the US, more than 1,400 babies will be born prematurely. Between the early 1980s and 2006, the rate of premature birth rose by 36%. These are fascinating and disturbing statistics, but as a midwife who is actively engaged in research, there is one companion statistic that startles me even more: From 1992 to 2002, the average gestational age at birth in the US dropped from 40 weeks to 39 weeks.

It does not take a statistician to appreciate that a drop in the average time a baby is born by a full week over the course of just 10 years means something big has been happening. Over 4 million babies are born each year in the US. A substantial increase in the rate of prematurity would be needed to reduce the average time of birth by a full week.

Why the rise in prematurity despite advances in medical knowledge and technology? According to the most recent March of Dimes prematurity summit, the primary reason is not obesity or smoking, as you might expect—it’s labor induction. In 1990, the rate of inductions was 9.5%. By 2006, the rate more than doubled to 22.3%.

Research documents that preterm infants have an increased risk of being admitted to level 2 or 3 nurseries and that important brain development continues all the way to full-term. More recently, late preterm infants (born at 34-37 weeks gestation) have been shown to have a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia.

Certified nurse-midwives and certified midwives have a long history of reserving labor induction for the situations when it is absolutely necessary. The American College of Obstetricians and Gynecologists (ACOG) recently issued a statement calling for an end to inductions prior to 39 weeks unless there is a clear medical indication. Now that the US has enough preemies to impact a national statistic and a national medical organization, let’s support a re-examination of medical indications for labor induction prior to full-term and promote a renewed emphasis on waiting for spontaneous labor and birth.

Monday, November 23, 2009

Click, Peel, Stick: How to Turn Holiday Cards into a Midwifery Advocacy Activity

by Melissa Garvey , ACNM Writer and Editor

Did you know that every year, Americans send 1.9 billion holiday cards? Today, ACNM is helping you turn this yearly task into a simple yet powerful advocacy activity with the launch of our 2009 midwifery stamps.

To participate, click on our stamps portal and follow the ordering instructions. Then place the stamps on your holiday mail to help raise awareness of midwifery across the country. Your purchase will also make a financial contribution to support midwifery. The A.C.N.M. Foundation will receive a portion of the sale for every midwifery stamps purchase that is made by a new customer.

Funded by the A.C.N.M. Foundation as part of the Public Education Project, the 2009 midwifery stamp was created by artist Kelly Moyer, winner of the ACNM Midwifery Art Contest. “This painting was inspired by the birth of my goddaughter,” says Moyer. “The image and colors represented best described the feeling at that time.”

Because midwives do more than care for pregnant women, our panel of judges appreciated that the painting portrays a non-pregnant woman and a baby. What do you like about the 2009 stamp?

Thursday, November 19, 2009

What Mammography and Continuous Electronic Fetal Heart Rate Monitoring Have in Common

by Melissa Garvey, Writer and Editor

Earlier this week the U.S. Preventive Services Task Force (USPSTF) issued revised breast cancer screening guidelines: women in their 40s who have no unusual risk factors for breast cancer should not receive routine mammograms for early detection of breast cancer and should instead begin routine screening at age 50.

This is proving upsetting especially to women who were diagnosed with breast cancer at a young age, which is understandable. At the same time, I can't help but wonder…is routine mammography for women in their 40s who have no risk factors for breast cancer akin to continuous electronic fetal heart rate monitoring (EFM) for all women with low risk pregnancies?

Fetal heart rate monitoring during labor is essential, but continuous EFM may send up red flags where none are needed. EFM readings vary by machine and clinician. Jump on an abnormal reading too quickly and you may end up with an unnecessary cesarean section—major abdominal surgery that carries heightened risks for both mother and baby.

In fact, ACOG recently revised their EFM guidelines and put it into perspective in a press release containing this insightful statement:
“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002," says George A. Macones, MD, who headed the development of the ACOG document. "Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions."
So, what about these revised breast cancer screening guidelines? Here’s a snapshot of the National Breast Cancer Coalition (NBCC) analysis of the revisions :
“Mammography can miss cancers that need treatment, and in some cases find disease that does not need treatment, leading to overtreatment with toxic therapies. Harms for healthy women who do not have cancer can include unnecessary imaging tests and biopsies, unnecessary exposure to x-ray radiation, and psychological trauma and anxiety.”
“All breast cancers are not equal. Some patients will have fast-growing, aggressive tumors while others will have slower-growing, less aggressive tumors that are less likely to metastasize and, therefore, have a better prognosis. Screening is more likely to identify the slower-growing, less aggressive tumors because of longer asymptomatic periods. This “length-time” bias can make screening appear more beneficial than it is.”
Notice any similarities to continuous EFM?

What do you think? Are these revised guidelines a step toward backing off of our nation’s overuse of technology and interventions? Or was this a bad public health move?

Tuesday, November 17, 2009

It’s Time to Fight For Preemies

by Melissa Garvey, ACNM Writer and Editor

In honor of National Prematurity Awareness Month, Midwife Connection is participating in the March of Dime’s Fight for Preemies, a blog event to raise awareness of the premature birth crisis. Every year, 20 million babies are born too soon, and half a million of them are born in the U.S. Today is the day to put a face on prematurity by blogging for a baby you love. We asked ACNM Facebook fans to tell us their stories. Here’s what they shared [please note that some comments were edited to preserve patient privacy]:

Cristal M Churchill
I took care of a lady who had twin-to-twin transfusion. She was being seen by MFM [Maternal Fetal Medicine] and OB due to her high risk status! Then she came in laboring and was c-sectioned at 30 weeks. We were so worried about them that first night. I remember being there and crying with them. As I finish my CNM degree, this family will always hold a spot in my heart.

Sharon Harkey
My beautiful IVF nieces born at 31 weeks because one was IUGR [intrauterine growth restriction]. Luckily, I started teaching OB clinical 2 days later at that hospital with a group of 8 RN students. It gave me precious access to the NICU to visit them while they grew over the next 6 weeks. They will be 4 in January and are doing wonderful, thanks to those awesome nurses! And all my students are out there practicing with a better view of OB thanks to taking clinical with a CNM!

Lisa Weston
My beautiful daughter, Zoe, now 17...preterm labor with dilation at 28wk, home uterine monitoring, terbutaline, SROM [spontaneous rupture of membranes] and delivery of my 4#8oz girl at 34 wk. So strong-willed, so mad at the world from day 1...always precocious, graduating from high school, a semester early (natch!) in 4 short weeks.

Leigh Wood
35 weeks gestation, his mom had prom [premature rupture of membranes] at 32 weeks and held him in and safe until she could deliver with us instead of at a tertiary care center.

Jackie Robins
My precious Eli and Vinny, preterm labor held off til 36 weeks. Eli had nasal CPAP for several days. Thank God for the advances in NICU care!!!!!

Let’s continue the fight for preemies. If you have a story about a premature baby you know or cared for, add a comment to this post. (Midwives and other health care providers, please remember to observe HIPAA privacy regulations. If you're not a health care provider, feel free to share as much as you want!)

Thursday, November 12, 2009

Moms Reveal Telling Facts About Breastfeeding

by Melissa Garvey, ACNM Writer and Editor

Did anyone listen to the Bravado Breastfeeding Information Council (BBIC) launch event this past Tuesday? I was pleasantly surprised by the amount of solid facts they revealed from their database of 80,000 women. In case you missed it, here’s a snapshot of what they shared:
  • First generation breastfeeding moms need special support. Of first generation breastfeeding moms (women whose mothers did not breastfeed), only 40% said they received amazing support from their mothers, 30% hoped for more support, and 10% were actively discouraged in their efforts to breastfeed.

  • Breastfeeding works better with three. 75% of women said their decision to breastfeed was influenced by their partner. As one woman explained, “Without his support, I would have given up in the first week.”

  • Being friendly to breastfeeding moms is good business. Business owners take note: more than 85% of nursing mothers will go out of their way to visit a store or restaurant that is breastfeeding friendly.

  • It’s easy to create a breastfeeding friendly workplace. More than 80% of breastfeeding mothers are committed to continue nursing when they return to work, and they say all they need is a door, a plug, a refrigerator, and a sink. Panelists shared innovative ideas worth passing along on this topic. At one company, moms are able to reserve the breastfeeding lounge via their Outlook calendar. Some companies are also including their breastfeeding policy in the maternity leave paperwork, so women have plenty of time to consider their options and plan ahead.
Did you listen in, too? Tell us what you learned.

(Note to women: More information about breastfeeding is available from the Journal of Midwifery & Women’s Health. Read Bringing Your Baby to Breast: Positioning and Latch and What to Expect in the Early Days of Breastfeeding.)

Friday, November 6, 2009

Woman to Broadcast Birth on Internet with a CNM

by Melissa Garvey, ACNM Writer and Editor

Lynsee is a 23-year-old who is pregnant with her first child and one of more than 4 million women who will give birth this year. But there’s something different about this teacher who lives with her husband in Minnesota. She plans to broadcast her labor and birth live on the Internet.

The couple’s choice is sparking a wide range of reactions, from fascination to curiosity to, as one reader commented, “Eeeuw! Disgusting....”

Lynsee’s decision isn’t for everyone, but it is her decision. And it may actually have a positive influence on public perception of birth. For starters, Lynsee’s care provider is a certified nurse-midwife (CNM), which is an option not enough women know they can choose. Now more than 1,500 readers of the Watch Lynsee Grow discussion group on know about their options thanks to this telling Q&A:
Question: Lynsee, will you use a midwife? I did not, yet have always wondered what it would have been like to have the attention and care of a midwife.

Answer: Yes I am using a midwife! She is amazing!! She takes the time to talk with me about my concerns in the appointments and is supportive of my decision to try to go as natural as possible with the birth! She also is not afraid to tell me that things will not always go as planned and that she may not be able to meet all my needs. There are many doctors in her office, and I will be seeing some of these doctors in case I end up needing one of them for the delivery. But my midwife is wonderful!! She even takes time out of her daily life to call me just to 'check in.' Never heard about that from a regular doctor!!
Lynsee’s upcoming birth (she's due on November 19) is at the height of a trend toward more transparency in labor, birth, and care decisions. With more than 3 million birth videos on YouTube, the Internet is exposing the reality of birth—and that’s something many women are hungry for.

Whether Lynsee has the natural birth she prefers, an emergency cesarean section, or something in between, I have to agree with the reader who commented: “Don't want to see it? Don't watch. There are plenty of people who do want to know how this all works.”

Thursday, November 5, 2009

U.S. Infant Mortality Rate Compares Poorly with Europe

by Melissa Garvey, ACNM Writer and Editor

Just in time for Prematurity Awareness Month, the CDC released a new NCHS Data Brief that ranks the U.S. 30th in the world in infant mortality rate. At 6.8 infant deaths per 1,000 live births (5.8 when excluding births less than 22 weeks of gestation), the U.S. falls behind most European countries, Canada, Australia, New Zealand, Hong Kong, Singapore, Japan, and Israel.

What’s the reason for our poor performance in this critical indicator of national health? It’s our “very high percentage of preterm births.”

Since 1984, the percentage of preterm births (infants born before 37 weeks of gestation) in the U.S. has risen 36%. Lowering that percentage appears to be the key to bringing the U.S. infant mortality rate in line with the rest of the developed world.

The Data Brief goes on to show just how dramatic lowering the preterm birth rate in the U.S. could be:
“If the United States had Sweden’s distribution of births by gestational age, the U.S. infant mortality rate (excluding births less than 22 weeks of gestation) would go from 5.8 to 3.9 infant deaths per 1,000 live births—a decline of 33%.”
Sweden and Norway have the lowest infant mortality rates in Europe. Here’s an interesting fact that was not included in the Data Brief: In stark contrast to the U.S., Sweden and Norway (along with most of the developed world) use midwives as their primary birth care providers.

Friday, October 23, 2009

Women Would Be Better Off If Reform Passes

While President Obama and congressional Democrats discuss the public option and the absence of bipartisan support for health care reform, a front-page article in Monday’s edition of Politico proposes that highlighting the particular importance of proposed reforms to women may be the key to successful reform.

Women have a lot to gain if health reform legislation passes. Protections mentioned in the article include:
  • Guaranteed maternity care
  • Elimination of higher insurance premiums for women
  • Protection from being denied coverage due to “pre-existing conditions” like cesarean section or domestic violence
Despite these protections that would address gender discrimination in health care, a Kaiser Family Foundation survey found that women are no more likely than men to think they “would be better off if reform passed.” According to the article, the problem is that women simply don’t know what is in the legislation for them.

Senator Sherrod Brown (D-Ohio) shared his perspective on just how monumental health care reform would be for women:
"Brown described the elimination of gender discrimination in health care as an historic advance comparable to landmark legislation prohibiting unequal treatment between men and women in employment, education and sports."
Do you know what’s in health care reform legislation for women? Learn more in an update from ACNM Federal Lobbyist Patrick Cooney or listen to his audiocast.

Wednesday, October 21, 2009

Peeling Back the Pink of Breast Cancer Awareness

by Melissa Garvey, ACNM Writer and Editor

Last weekend the National Breast Cancer Coalition (NBCC) launched an Emerging Leaders workshop—a program designed to train the next generation of breast cancer advocates. I attended as an ACNM staffer and was struck by the parallels between breast cancer advocacy and birth advocacy.

What I found most fascinating was the amount of misinformation about breast cancer that circulates in the media, the health care system, and even scientific peer-reviewed journals. Just as birth advocates challenge women and health care providers to reach beyond the traditional, medical model of birth practice to evidence-based, woman-centered care, NBCC is blowing the whistle on breast cancer screening, prevention, and treatment practices that are neither scientifically sound or patient friendly.

In honor of Breast Cancer Awareness Month, here are a few myths and truths from NBCC:

True or False?
  1. Monthly breast self exams save lives.
    FALSE. The evidence actually shows that breast self exams (BSE) do not save lives or detect breast cancer at an earlier stage.

  2. Most women with breast cancer have a family history of the disease.
    FALSE. Eight out of nine women who develop breast cancer do not have an affected mother, sister, or daughter.

  3. Mammograms can only help and not harm you.
    FALSE. False positive results may lead to unnecessary, intrusive surgical interventions, while false negative results will not find cancerous tumors.

  4. Hormone replacement therapy (HRT) increases your risk of breast cancer.
    TRUE. According to the Women’s Health Initiative (WHI) Postmenopausal Hormone Therapy Trials, an estrogen-plus-progestin replacement therapy increases the risk of breast cancer, heart disease, stroke and blood clots.
As a woman with no family history of breast cancer, myth #2 is the most surprising to me. Which of these myths and truths most surprises you?

Friday, October 9, 2009

My Midwives' Gifts of Care: Empowerment, Patience, Attention

Today’s blog post was written by a midwife supporter – Karen Yurish.

While I received numerous gifts of care from my midwives during my pregnancies and deliveries, the three I treasure most were their empowerment, patience, and attention. While in the tender stage of early pregnancy, it was easy to feel overwhelmed by everything new. From the first time I saw my midwives, I felt empowered--they trusted me to make the best decisions for myself and my baby and they trusted my body to successfully and safely birth my child. That reassurance at every prenatal visit gave me great confidence going into labor.

That confidence enabled me to trust my body through a day and a half of prodromal labor with my first daughter. In a birthing environment that often puts laboring women on a strict time schedule, the midwives waited patiently for my body to labor in its own way. I had returned home after my first visit to the hospital 12 hours into my prodromal labor, and the midwives trusted me to come back to the hospital when I felt my body was ready. After 36 hours of contractions that were never more than 10 minutes apart, I returned to the hospital and was delighted to learn I was finally dilated to four centimeters. My midwife‘s patience continued through my labor, sitting with me while I labored in the tub, supporting and encouraging me as I dilated the last few centimeters and breathed my way through transition, and patiently massaging my perineum through 45 minutes of pushing so I didn’t tear.

Finally, I am grateful for the attention I received from my midwives. Each prenatal visit ended with asking me if I had any questions--and I never felt rushed out of the office. They paid great attention to the details of the environment where I labored and delivered -turning off the fluorescent lights and bringing in a lamp for softer light, running the tub and keeping it warm, bringing me a pillow to use as I labored in the tub, warming me with hot blankets when I started to shake uncontrollably as I transitioned. They helped me try different laboring positions, refocused me, and attentively followed every aspect of my birth plan.

I am grateful for these gifts of care from my midwives; I feel blessed to have had such wonderful birth experiences.

Thursday, October 8, 2009

Meet the Future of Midwifery

Why become a midwife? These passionate students share why midwifery is, without a doubt, their professional calling.

Five years have passed since I…first heard the word “midwife.” Now, I am two months away from completing the nurse-midwifery program at Georgetown University. I am a midwife because I care about women and their health…I care about empowering women to educate themselves about their bodies so they can make informed decisions… I am a midwife because I am concerned about more than just the physical health of the woman. I care about her family, her work life, her home life, and what keeps her awake at night. I give her a hug and tell her that I am proud of her – perhaps the gentlest touch and kindest words she has heard in months. I am a midwife because I want to make a difference.
-Allison Stitsworth, RN, BSN, SNM, Georgetown University

I have often been asked why I didn’t choose to become a physician. My answer is simply that I want to be a midwife. Midwifery encourages me to truly be a partner with the women under my care…it provides an opportunity to offer real service to fulfill a specific health or wellness need—whatever is most important to the woman I serve. As a student midwife, a mere three months away from graduation, I can honestly and confidently say that I chose the right path….To anyone contemplating a similar journey I say: jump in with both feet and give it all you have.
-Janelle Green, SNM, Georgetown University

Is midwifery calling you? Find out at Become a Midwife.

Birth in 50 Words or Less

Can you tell your birth story in 50 words or less? Yesterday, the women of started the challenge in honor of National Midwifery Week. Here is a sampling of the stories that rolled in:
  • It was a wonderful pregnancy and a wonderful birth. I met my midwife at the hospital at about 5 p.m. She was patient and calm. She was by my side throughout my labor. I started pushing at about 10 p.m. At 1:13 a.m., my beautiful boy joined my whole family in that room. –Maria

  • Twenty-four hours of labor and a beautiful birth, a perfect outcome. My husband, our mothers, my son, our birth helpers and my midwife stayed by my side, coaxing my little girl into the world at her pace with only whispers and gentle words and loving touch. My midwife, my midwife! –Ania

  • Birth Haiku for Baby 2: Waiting and screaming. Baghdad on fire, and me too. War and life begin. –Candice

  • First VBAC... I didn't believe I'd really push him out until his head was halfway out. I knew everyone expected a repeat section. But out he came and was placed on my chest. I grabbed one arm and one leg and cried... so grateful for the experience and my baby! –Christine

  • First birth...long labor. I kept thinking this isn't how the books say it is supposed to be. Second birth....long labor. Two healthy babies, the goal. Yeah! –Caroline
What’s your story?

Wednesday, October 7, 2009

How Do You Practice Real Midwifery?

by Leslie Ludka, CNM, MSN

Editor’s Note: In honor of National Midwifery Week, we asked Leslie Ludka to write an encore post based on her article “Are You Practicing Real Midwifery?” (click on the article for a sneak peak at Quickening, ACNM’s members-only newsletter!). Leslie is a regular columnist for Quickening and is Director of Midwifery at Cambridge Hospital and Birth Center in Cambridge, MA.

Whenever I think about midwifery as a career, I remember Sister Angela Murdaugh’s words: “Midwifery is a calling. If you do not believe that you were called, you should get out of midwifery.”

But, how do we know if we were called? Does it have to manifest in a specific type of job in a specific type of setting? Is it only a calling if we can’t wait to get up every morning and rush to work? Does being financially successful make it a calling?

I’m not sure about you, but for most of us, midwifery is neither easy nor lucrative. In fact, there are times when midwifery is the hardest job in the world—just ask any midwife to tell you the story of that case that haunts her memories. We all have one. In fact, there are times when our work is so difficult that no amount of money would attract most rational people.

So, why would anyone choose midwifery? I believe that Sister Angela has it right. Midwifery is not a choice; it is a calling. We do not choose midwifery; midwifery chooses us. When I went to midwifery school, I never asked if there would be a job for me when I finished. I didn’t wonder how much money I would make. I know it sounds crazy, but the truth is, it didn’t matter. Midwifery is my calling.

A calling fulfills your personal mission in life. It feeds your spirit by using your unique gifts and abilities to satisfy your deep inner purpose. Following your calling means staying on the path of that which you feel most passionate about, even when it is difficult. A calling is about truly loving what you do.

As we celebrate National Midwifery Week, let’s honor the diversity of this amazing calling of midwifery by sharing with each other and our supporters. Tell us, how has midwifery called you: clinical practice, education, administration, or something else? How do you live your calling?

Tuesday, October 6, 2009

A Man’s Perspective on Midwifery and Gender

by Peter Johnson, CNM, PhD, FACNM

As a man who has dedicated his career to midwifery, I frequently answer questions like “How can you be a midwife?” “Aren’t you a mid-husband,” and “Don’t you want to be called something else?”

When I answer these questions from family, new friends, and acquaintances at parties, I give a simple answer. Midwife means “with woman.” The gender of the person with that woman is not the relevant factor. What is relevant is that the midwife—regardless of race, ethnicity, religion or gender—is practicing midwifery. The hallmarks of midwifery, like the belief that birth is normal, that skillful communication is a necessity, and that women benefit from the sustained presence of another caring human, are what make our profession unique.

Recently, however, I was approached with a thought-provoking ethical dilemma: How does midwifery guard against gender discrimination toward midwives who are men while simultaneously honoring the rights of women who prefer female care providers?

There are circumstances where women for religious, cultural, or personal reasons desire the care of another woman. Of course, this desire must be honored. I have, however, seen job ads saying “All-female OB/GYN practice seeking midwife” and hospital policies forbidding male nurses or midwives on labor and delivery. These practices make the dangerous assumption that all women seek women for their care, and these practices are discriminatory and dangerous.

Right now far more women are entering medical obstetrics than men, and many of those women are not delivering midwifery care. It is important that midwives and their supporters recognize that the care we know women deserve is not directly related to the gender of the care provider.

Midwives, what are you doing to encourage men in midwifery to join your practice, office, or university?

Women, does the gender of your midwife matter to you?

Monday, October 5, 2009

To Take or Not to Take the H1N1 Vaccine

by Eileen Beard, CNM, FNP

This week, the first doses of H1N1 (swine flu) vaccine will begin arriving at midwifery practices around the country. Although government agencies and health care providers are urging pregnant women to get the seasonal flu vaccine as well as the H1N1 flu vaccine, some women remain hesitant. Pregnancy is a time to avoid caffeine, alcohol, and unnecessary medications. So, why make an exception for a new vaccine?

As a certified nurse-midwife and mom of five (plus five step daughters!), I am typically cautious about new products. When it comes to H1N1 flu, however, I am absolutely convinced that vaccination is a must.

Because of the normal changes of pregnancy (for example, decreased ability to fight off infections), pregnant women are especially susceptible to the harmful effects of H1N1 flu. Research consistently shows that pregnant women are at increased risk for serious illness and even death from H1N1 infection and are four times more likely to be hospitalized.

If you’re still on the fence about vaccination, consider this: for the first time ever, a national coalition of eight organizations (including ACNM, March of Dimes, ACOG, and AWHONN) has come together to develop a clear statement about the seriousness of H1N1 flu and the importance of receiving the vaccination. This sends a pretty clear message in favor of heading to your midwife to receive that vaccine.

If one of your worries is thimerosal, a controversial component of vaccines, about half the doses of H1N1 flu vaccine to be released this fall are thimerosal-free and will be prioritized for children and pregnant women. Ultimately, only you can decide what is best for you and your family. I encourage you to give this issue serious consideration and make a decision as an informed health care consumer.

Need more information to make your decision? Check out these helpful resources:

Friday, October 2, 2009

Midwives Included in Health Care Reform

National Midwifery Week (October 4-10) starts this Sunday, and we have some wonderful news to kick off the week. Equitable reimbursement for certified nurse-midwives (CNMs) under Medicare is now included in both the House and Senate health care reform bills!

The midwifery equity provision made it into the Senate bill last night after Senator Kent Conrad (D-ND) introduced it as part of an amendment in the Senate Finance Committee.

In the coming weeks, the Senate bill and the House bill are expected to come up for vote in both chambers and are widely projected to pass. As it stands now, the only thing between CNMs and 100% reimbursement for their services under Medicare appears to be President Obama’s signature.

While this is a major step forward for the midwifery community, ACNM’s parallel effort to win inclusion of certified midwives (CMs) under Medicare and Medicaid was not successful. We’ve already identified additional strategies for continuing to pursue reimbursement for CMs.

Meanwhile, hats off to Senator Conrad for introducing the amendment and to Senator Blanche Lincoln (D-AR) for saying, “Without a doubt, the certified nurse-midwives in Arkansas have done a tremendous job and I want to thank Sen. Conrad for moving forward with that.”

Let the National Midwifery Week celebrations begin!

Tuesday, September 29, 2009

What do Midwives and Women Think about Health Care Reform?

In August, ACNM endorsed the House health reform bill, H.R.3200. This week we're watching closely as the Senate Finance Committee is finalizing its own version of the legislation. These are controversial pieces of legislation. So, tell us what you think! Let’s voice our opinions and share informative resources to fuel the discussion. Is health care reform good for women, midwives, Americans? What do you like about the unfolding legislation? What don’t you like about it?

Here are few resources to get the conversation started:

Friday, September 18, 2009

ACNM Invited to First Lady's Health Care Reform Discussion

This morning, ACNM Executive Director Lorrie Kaplan attended a White House event hosted by First Lady Michelle Obama designed to call attention to the deficiencies in our current health care system for women and their families.

“Women are being crushed by the current structure of health care,” said Obama. “If you're not experiencing it yourself, you know someone who is. This is why we are fighting so hard for health care reform. I invited this particular group of family advocacy groups and health care advocacy groups here today because your organizations have been fighting for decades for the empowerment of women.”

Obama recalled two particular incidents in which her family was affected by the US health care delivery system and aided by the health insurance they carried.

"This is very much a women's issue," she asserted. “The current system is unacceptable. We have to reform this system because it is holding women and families back.”

The bottom line? “When you're fighting an illness, you should not have to fight your insurance company at the same time. Getting sick should not mean that you will go bankrupt.”

ACNM has strongly supported health care reform as one of its top federal legislative priorities of this Congress. Read more about ACNM's federal legislative activities .

Tuesday, September 15, 2009

Mad Men and Birth, Sixties Style

Sunday night’s episode of Mad Men brought 60s-style birth to prime time TV. The moment that mother/wife Betty matter-of-factly proclaimed “It’s time,” birth activists across America probably sat poised on the edge of their couches anxious to see how the show would portray this birth. Contrary to typical television births, Betty and father/husband Don calmly proceeded to the hospital—no rush, no alarm, no emergency mode. In fact, most of what followed matched the reality of what it was like to give birth in the 1960s.

Upon arriving at the hospital, Don retired to the waiting room. Betty was “prepared for delivery” with a shave and a dose of twilight sleep (morphine and scopolamine). As the effects of sedation set in, Betty became a belligerent, sweaty, laboring woman hovering somewhere between painful reality and a drug-induced dream world. Hours later, she woke up with a baby in her arms and Don by her side.

Set in the early 1960s, Mad Men is littered with unfair treatment of women in the home and in the workplace. Watching this series has caused many female viewers to closely examine ways that they may be mistreated as women in today’s society—ways that they simply accept as part of the way things are. Maybe Sunday night’s episode of Mad Men will cause women to question the routine parts of modern birth and to wonder if we could (still) be doing better.

Monday, September 14, 2009

Dear Today

This afternoon, ACNM sent this letter in response to The Today Show segment “The Perils of Midwifery” (later renamed “The Perils of Home Births” online). We encourage midwives and their supporters to send their letters to and to adapt ACNM's letter for their own use to share with coworkers and clients. Thank you to the many ACNM members who have already sent letters in support of midwifery and homebirth.

Friday, September 11, 2009

The Non-perils of Midwifery

Earlier, the Today Show aired a sad, unfortunate piece called “Perils of Midwifery.” (They later updated the Web segment title to "Perils of Home Births.") Not only does it follow the heart-breaking account of a birth gone horribly wrong; it exploits the couple’s tragedy—turning it into a sensationalized story that scares women and grossly misrepresents midwifery.

The safety of midwife-attended births is well documented in a substantive and ongoing body of research. If ACNM, the professional organization for certified midwives and certified nurse-midwives, had been consulted during the development of this piece, the Today Show’s journalists would have known about these top 5 fact-based resources from the past year:
  1. Evidence-Based Maternity Care: What It Is and What It Can Achieve says that midwives top the list of “underused interventions” that should be used “whenever possible and appropriate.” Several systematic reviews showing improved outcomes associated with midwifery-led care are cited.
  2. A Cochrane Review concluded that “most women should be offered midwife-led models of care.”
  3. A study published in the British Journal of Obstetrics and Gynaecology found that planned homebirth is as safe as hospital birth for women with low-risk pregnancies.
  4. Just last week, Canadian researchers declared that “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death…and other adverse perinatal outcomes compared with planned hospital birth....”
  5. Authors of an American Journal of Obstetrics & Gynecology article say they encourage midwifery care and “support future randomized trials to compare” home vs. hospital births.
Women and health care professionals need to be making decisions that are informed by evidence-based medicine—not reactionary interventions and unbalanced investigative journalism. Women deserve better.

Thursday, September 10, 2009

Join the Fight Against Preterm Birth with March of Dimes

Did you know that preterm birth has increased by 20% over the past two decades? In our country, one in eight infants is born prematurely. That’s nearly half a million babies each year.

The March of Dimes (MOD) is inviting a multidisciplinary group of health care practitioners, health insurers, policy makers—and concerned citizens—to address this growing problem. On October 8 and 9, MOD, in collaboration with American College of Nurse-Midwives (ACNM), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), and Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), will sponsor the Symposium on Quality Improvement to Prevent Prematurity at the Hyatt Regency Crystal City in Arlington, VA.

In addition to presenting an impressive lineup of speakers, including ACNM President Melissa Avery, CNM, and Nancy Jo Reedy, CNM, the event aims to create an action plan to reduce premature births that are not medically necessary. Attendees will discuss quality improvement as an essential component in the strategy to prevent prematurity, promote health, and reduce costs. (We expect this will include underutilized strategies such as midwifery care!)

Register by Friday, September 11, and pay $200. (After Friday, the price jumps to $250.) Groups of 10 or more from one institution can e-mail to discuss a discounted registration fee.

Friday, September 4, 2009

Persistence Pays for Minnesota Midwife

by Brielle Stoyke, CNM, Minnesota Chapter Legislative Contact

Senator Al Franken and Brielle Stoyke, CNM

In December 2007, I was invited to a fundraiser for Al Franken. Franken was running for a Minnesota Senate seat. I went that night thinking maybe there would be an opportunity to talk to him directly about S. 662, the Midwifery Care Access and Reimbursement Equity Act, just in case he was elected. I didn’t get to talk to him long enough to mention midwifery, but I got my photo taken with him, which I tucked away for later.

He ended up winning the Senate seat, and I attended his celebration party in St. Paul. He had only been in office a few days and did not have a full staff yet. I didn’t even get near him that night, but was able to get the name of his new legislative health aide. So, I went home and e-mailed her about being a midwife, and specifically about S.662, and was sure to attach the photo of Franken and me from the 2007 party. Next, I e-mailed many of the CNMs in MN urging them to ask the senator to cosponsor S. 662.

Just a few weeks later, I was in my hometown of Duluth, MN, where I was offered an extra ticket to an event that Senator Franken was attending. I went with some friends, and we arrived an hour early. The venue staff were not seating yet, so we went across the street for a drink. When we arrived, we were pleased to find a private party in honor of the senator. I instantly recognized the staffer from the celebratory party in St. Paul and was talking with her, when I noticed a lull at the senator’s circle. So, I approached him and told him that I was a nurse-midwife from St. Paul and that I wanted him to cosponsor S. 662. He asked about the bill, and I told him it would increase reimbursement rates to midwives under Medicare. He looked puzzled. So, instead of explaining the details, I told him that I had been in contact with his legislative health aide, that S. 662 would provide equal pay for equal work, that his Senate partner Amy Klobuchar had signed the bill already, and that the bill had no opposition. He then asked me about my training, and I was proud to tell him I had a master’s degree in nursing, with a focus on midwifery. Right then one of my friends approached us with a camera and captured ‘my moment’ with the Senator on camera again! I followed up with his legislative health aide later that week and sure enough, he signed onto S. 662 just six short days later!

What did I learn from this experience? Success comes after persistence and teamwork. Never let an opportunity pass to talk to your legislator about what you do and why midwives deserve equitable reimbursement. Thanks to my fellow MN midwives for following up as well, and thanks to Senator Franken for supporting our bill!

Thursday, August 27, 2009

How Pregnant Women and New Moms Should Prepare for H1N1 Flu

Midwives, pregnant women, and new moms, watch this webcast for the latest on what you should know about H1N1 flu. Features questions from the public and answers by experts from ACNM, CDC, and NIH.

Tuesday, August 25, 2009

ACOG Encourages Laboring Women to Quench Their Thirst

Women who decide to give birth in a hospital may soon have access to more than ice chips during labor. The American College of Obstetricians and Gynecologists (ACOG) just released a committee opinion recommending that clear liquids (water, juice, sports drinks, etc.) be provided to women who have uncomplicated labor or are scheduled for a planned cesarean.

ACNM has long supported a liberal approach to providing oral nutrition to women in labor, including drinks and solid food. But for decades, many hospitals have restricted women’s oral intake for fear of aspiration—a potentially fatal occurrence that involves stomach contents entering the lungs while a woman is under anesthesia. Thanks to improvements in anesthesia, aspiration in pregnant women is now extremely rare.

Midwives emphasize that birth is a normal process that under normal circumstances does not require fasting. They educate clients about the small but potentially serious risk of aspiration and watch women throughout labor to identify when food and drink need to be restricted. While ACOG’s latest weigh-in is old news to midwives, hopefully it will encourage more hospitals to adopt less restrictive, more woman-centered policies.

Friday, August 21, 2009

Midwifery News Roundup

At ACNM, we’re busy celebrating the 1000th baby born at Special Beginnings Birth and Women's Center and preparing for the next issue of Quickening (our newsletter for midwives). Until next week, check out these news links that we think are worth sharing:

Note: If you're viewing this on facebook, visit to view the links in the post.

Friday, August 14, 2009

Uninsured Women Lose Access to Midwives in South Carolina

On September 30, the five midwives providing services at the prenatal program at North Central Family Medical Center in Rock Hill, SC, will be out of work, and the uninsured women and families they serve will lose access to midwifery services. The clinic is planning to end the prenatal program because it has become too expensive.

Specifically, North Central says it is too expensive to renew their contract with the midwives’ employer, Piedmont Medical Center. Studies have shown that midwifery care saves money—and lives—through reduced risk of prematurity and low birth weight. So, why wouldn’t North Central want to pay for it?

A big part of the problem is that midwifery services for uninsured and underinsured women and families are paid through Medicaid, which does not foot the entire bill. Medicaid does not always reimburse midwives for the full cost of their services, and it does not cover legal immigrants who are a large part of the patient population at the clinic. If the situation continues as is, North Central says they will be an estimated $200,000 in the hole by next year.

Ending the prenatal program is, at best, a stop-gap solution. No matter what a woman’s insurance status, she won’t just stop being pregnant. She needs care. As one reader so eloquently commented:

“If North Central says it will lose $200,000 each year if the current midwife contract arrangement were to be continued—all it takes is ONE very premature, low birth weight baby to be born to a local mother who goes with NO PRENATAL CARE, and you're talking about a $200,000 to $300,000 intensive care nursery bill at Palmetto-Health Richland Hospital in one fell swoop!!!”
Simply put, eliminating midwifery services will magnify and shift the bill to someone else’s budget—the hospital and the tax payers who ultimately pay for Medicaid.

Tuesday, August 11, 2009

Washington State Stacks Financial Incentives in Favor of Vaginal Birth

The state of Washington is taking an innovative step toward tackling rising cesarean section rates by eliminating the profit motive. Beginning this month, the state’s Medicaid reimbursement for uncomplicated cesarean sections dropped from approximately $3,600 to about $1,000—the same reimbursement provided for complicated vaginal birth.

Because the cost of vaginal birth is lower than the cost of c-section, the new payment structure rewards health care providers for supporting vaginal birth rather than for performing c-sections. Nearly half of all births in Washington are reimbursed through Medicaid, so the change is expected to have far-reaching effects. In fact, the state has already received calls from hospitals requesting assistance to revise the protocols they use to decide when a cesarean section is necessary.

A recent article by Carolyn McConnell explains why this is an excellent way to improve maternal and infant health. It’s also in line with #5 and #7 of ACNM’s Seven Key Principles for Health Reform.

What do you think? Would you like to see the rest of the country adopt Washington’s new strategy?

Friday, August 7, 2009

Wilmington (NC)Women Ask, “Where’s My Midwife?”

Women receiving prenatal, postnatal, and routine gynecologic care at Carolina OB/GYN in Wilmington, NC, were surprised last week to find that midwifery services were eliminated from the practice. Patients were told to reschedule their visits with an obstetrician instead. Due in part to restrictive state laws governing midwife-physician collaboration, this change leaves local women seeking midwifery services with little to no alternatives.

One woman is 7.5 weeks away from delivery, and a commenter on WECT- Channel 6 News’ website says she found out her midwife was no longer with the practice when returning for her postnatal checkup just two weeks after giving birth.

Carolina OB/GYN stated, “This decision was based solely on operational requirements, not financial or quality issues.” North Carolina women are asking, “Where’s my midwife?”

Image source:

Tuesday, August 4, 2009

The Real Risk of Late Prematurity

A study in the August 2009 issue of Obstetrics and Gynecology shows that late prematurity is an independent risk factor for neonatal morbidity. For those of us who aren’t women’s health experts, that means babies born between 34 and 37 weeks of pregnancy are at greater risk for health problems than babies born on or after week 37.

Midwives already know that late prematurity puts babies at risk for complications, but this retrospective study involving nearly 10,000 low-risk pregnancies singles out late prematurity as an independent risk factor. After adjusting for potential confounders, including maternal age, birth weight, and mode of delivery, researchers found a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia in babies who were born at 34 weeks. Researchers also observed a “gradual and consistent decrease” in risk of neonatal morbidity as gestational age increased with risks leveling off at about 39 weeks.

Study authors note that late prematurity has increased dramatically over the past two decades to about 8% of all deliveries and 75% of preterm deliveries. Interestingly, ACOG recently revised their labor induction guidelines, encouraging avoidance of induction before 39 weeks of pregnancy (the previous recommendation was 37 weeks). Do you think this study had anything to do with this?

Tuesday, July 28, 2009

ACOG Revises Labor Induction Guidelines

Midwives are applauding the American College of Obstetricians and Gynecologists (ACOG) latest revision to their labor induction guidelines. The new ACOG practice bulletin recommends avoiding labor induction before week 39 of pregnancy—an improvement over the previous 37-week recommendation.

This comes on the heels of more good news: a recent study at Brigham and Women’s Hospital in Boston found that 10-year episiotomy rates have steeply declined, thanks to peer pressure to stop performing the procedure as well as significant research on the topic. A Medscape article also says that researchers acknowledge "several other contributing factors, including long-standing CNM service in hospital-based practice, and the addition of CNMs to Harvard Vanguard Medical Associates in 1990."

Midwives may be blue in the face from their decades of trumpeting the need for judicious use of interventions, but it looks like their music has not fallen on deaf ears.

Thursday, July 23, 2009

Denis Walsh, mommy wars, and coming together On Common Ground

Originally published on Science and Sensibility by Amy Romano, CNM, for Lamaze International

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

Introducing Science and Sensibility

Blogger Amy Romano, CNM, and Lamaze International have graciously agreed to share their posts from Science and Sensibility with Midwife Connection readers. Check back for periodic Science and Sensibility posts that are of interest to midwives and midwifery fans.

Friday, July 17, 2009

Nurses Stand with Obama; Are Midwives Next?

by Dawn Durain, CNM, ACNM Vice President

I was trying to find some news coverage on the Sonia Sotomayor hearings on Wednesday afternoon, when suddenly there was President Obama on the White House steps surrounded by women! This being an atypical sight, I quickly unmuted. As it turned out, the people accompanying the president were mostly nurses and members of the Congressional Nursing Caucus—nurses in the Rose Garden! Nurses were being praised by the president for their dedication, ability to convey complex information to patients, and skills in caring for women in labor and their nervous husbands—all of this from the personal experiences of President Obama no less.

The occasion of the speech was, of course, to mark a significant step by Congress toward health care reform. I encourage you to read the Senate and House legislation and the president’s speech for yourself. I find the recognition of the work of nurses refreshing—more refreshing than the recent spate of TV shows featuring nurses for sure! I found myself hoping for the impossible though. Would the president mention nurse-midwives when he spoke of his experiences when his daughters were born? He didn’t. Would he mention the importance of nurse practitioners, certified nurse-midwives (CNMs), and certified midwives (CMs) as primary care providers when he spoke of the need for coordinated health care? He didn’t do that either. But, the legislation he referenced does, thanks to the hard work of our ACNM staff and midwives around the country who are talking and talking and talking to their representatives in Congress. Wednesday felt like a giant step forward. And maybe next time the White House will invite a midwife to the Rose Garden!

On a personal note, I’d like to give a shout-out to Keisha Walker, one of the nurses President Obama introduced who was there with him. She is a graduate of the University of Pennsylvania Graduate School of Nursing and worked on two projects in my Public Policy class at UPenn. She was passionate about nurses being involved in the political process and about the ability of nurses to have an impact on reproductive health care policy. She is currently at Johns Hopkins as a nurse researcher in their MPH program and clearly still involved in health care policy. Way to go, Keisha! Who is next in line to talk to the president about midwifery?

Wednesday, July 8, 2009

WRA Reminds G8 to Pay Attention to Moms

As world leaders come together at the G8 meetings in Italy this week, the White Ribbon Alliance (WRA) has launched a new video and an Atlas of Birth to draw attention to the problem of maternal death during childbirth.

According to WRA, maternal death is the greatest health inequity of the 21st century. Every minute, a woman dies while giving birth. In fact, more women die in the developing world from pregnancy than from any other cause.

Earlier this week, certified nurse-midwife Anne Hyre, director of the ACNM Department of Global Outreach, joined WRA delegates to present a petition to the US Ambassador-at-Large for Global Women’s Health Issues from millions of health care workers urging action at the G8. What can you do to help? Join WRA (it’s free!), and remind world leaders of their promise to correct the scandalous state of global maternal health. Visit the White Ribbon Alliance online to learn more about how you can take action for the cause.

Image source: White Ribbon Alliance

Left to right: Catharine Taylor (WRA Board Member & Director of Maternal, Child Health and Nutrition at PATH); Anne Hyre (Director of Global Outreach at the American College of Nurse-Midwives); Betsy McCallon (Deputy Director of White Ribbon Alliance); Melanne Verveer (U.S. Department of State's Ambassador-at-Large for Global Women's Issues); Rachel Vogelstein (U.S. Department of State, Senior Policy Advisor); Jen Klein (U.S. Department of State).

Thursday, July 2, 2009

CNM/CM Medicare Reimbursement Legislation Included in House Health Reform Bill

Senate Medicare bill (S. 662) has 18 co-sponsors and counting!
by Laura Jenson, CNM, MS

So, the best thing about making that first phone call to my representative’s health legislative aide was finding out how easy it is. Sure, I had made quick phone calls in the past to legislators’ offices asking that they support this or that bill, my zip code is 60623, OK, thank you very much, bye! But I had never phoned a health legislative aide (or “health LA” if you want to sling around some jargon) with the intention of having an in-depth conversation about legislation until this winter . . .

When I first spoke with the health LA for my representative, Luis Gutierrez, about H.R. 1101, she wasn’t even totally sure what a midwife was. I honestly kind of stumbled through that conversation and then followed up with a couple of e-mails with letters of support for the legislation from various organizations like ACOG, the ANA, the National Perinatal Association, and the National Rural Health Association. I called her back a couple of times to check in, and then to my great surprise, Rep. Gutierrez’s name showed up a few weeks later on the co-sponsor list for the bill! (Love – you can get loads of information about a bill; the old standby, is good, too). It was such a great feeling to see that my little amount of work made a difference, and now I’ve got a new little hobby.

Seriously. Once I started poking around looking for resources, I found that most everything you need is online, and ACNM has put it all in one place. You can go here to find information about the Medicare equitable reimbursement issue that’s so important right now, especially because of the health care reform legislation that’s being drawn up. If you want to find out who your elected officials are, just go here. (I had to go to the USPS site first to find my four-digit zip code extension to figure out who my one representative was.) There are also loads of people on the ACNM Government Affairs Committee (or the “GAC”) who would love to help with any questions you have about this process—e-mail me at if you’re interested in finding out who’s in your region.

Why get involved? Because more phone calls means more legislators signing on as cosponsors, and more co-sponsors means our bill has a better chance of being attached to some larger health care legislation. The Medicare reimbursement issue is a top agenda item right now—let‘s make this happen! The legislation has already been included in the House health care reform package (go team!), and now it’s important that it be included in the Senate version. If you’ve read this far, how about taking a couple more minutes to give your Senators a call? Go here to learn more.