Supporters Join Forces to Save Terre Haute Midwives

by Melissa Garvey, ACNM Writer and Editor

A group of midwives at Union Hospital in Terre Haute, Indiana, have been notified that their employment contracts will not be renewed this year. It’s a familiar situation—one that we saw play out in Wilmington, North Carolina, about this time last year.

The midwives’ last scheduled day at the hospital is October 29, but a dedicated group of supporters is refusing to stand by as the date approaches. Prompted by outrage, their love of midwifery, and a little help from Where’s My Midwife?, Friends of Wabash Valley Midwifery have organized to fight for their community’s midwives. They are on their second letter to the hospital and their third action meeting. Meanwhile, their Facebook group has grown to 113 members who are prepared to picket if the group so decides.

Want to show your support for Terre Haute midwives? Here’s how to help:

• Join the Friends of Wabash Valley Midwifery group on Facebook and stay tuned to updates and calls for action.
• Organize or participate in a Where’s My Midwife? Walk for Moms and Midwives on Saturday, October 9, during National Midwifery Week.
• Sign the Save Our Midwives! petition.
• Help spread the word by sharing this post, the Friends of Wabash Valley Midwifery group, and the Walk for Moms and Midwives with coworkers, friends, and family.
  

ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].

ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.

Read more [PDF]

Access to Midwifery Care Improves Maternity Outcomes

by Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy

The Patient Protection and Affordable Care Act will bring millions of newly insured citizens into the health care system. In order to meet the country’s needs, leaders are calling for high value, evidence-based solutions. Let’s start with the health condition that affects 100% of all Americans...childbirth! How can we provide high quality, high value maternity care for all women and families? The answers are in the evidence: midwifery care improves maternal and newborn outcomes and patient satisfaction, reduces health disparities, and saves money and resources.

The U.S. grossly outspends every other nation per capita on health care, yet our maternal and newborn outcomes lag far behind those of other developed nations. Childbirth is the number one reason for hospitalization, and its related hospital charges surpass those of any other health condition. Resource-intensive interventions like labor induction, epidural analgesia and cesarean section are overused, often without indication or consideration of alternatives, resulting in increased risk of maternal and newborn harm.

Cesarean section is the single most common operating room procedure in the U.S., and the rate is steadily climbing. Incredibly, in 2007, nearly one-third of American women delivered their babies by cesarean section. Maternal mortality has risen dramatically, and glaring racial disparities in maternal and neonatal outcomes persist.

How can we reverse these disturbing trends? Ensure that all women have access to maternity care providers and practices that support the normal processes of birth. Labor support, freedom of movement, intermittent monitoring, alternative birth settings, vaginal birth after cesarean...all have been identified as evidence-based practices that are underused.

Midwives truly are the experts in supporting healthy vaginal birth in all settings. Midwives caring for low-risk women improve infant mortality rates in both hospitals and birth centers when compared with physicians caring for equally low-risk women. Midwife-led models of group prenatal care reduce preterm and low birthweight rates and improve patient satisfaction. Birth centers provide improved outcomes for even the most at-risk women, reducing preterm birth, low birthweight and cesarean section rates, and reducing costs to our health care system. Skilled midwifery care is the gold standard among nations with the best maternal and neonatal outcomes, and has been identified as essential to reducing maternal mortality worldwide.

It’s time to bring that message back home. The time is now to promote and support midwifery in America—and to follow the evidence.

This post was originally published on the the Center to Champion Nursing in America (CCNA) blog. Visit CCNA to join more conversation about this post.

Labor Induction: The Back Door to Reducing Cesarean Rates?

by Melissa Garvey, ACNM Writer and Editor

A study in the July 2010 issue of Obstetrics & Gynecology underscores why the midwifery model of care—a model which minimizes interventions—should be the standard of care for women. Researchers set out to investigate the link between labor induction and cesarean birth, and discovered some telling findings.

This retrospective study examined the electronic hospital clinical records of nearly 8,000 women who had never given birth, were pregnant with only one baby, experienced head-first (specifically, vertex) presentation of the baby at birth, and were between 37 and 42 weeks of pregnancy. Of the group, 43.6% underwent induction of labor—39.9% of which were elective. That means that instead of being medically necessary, the labor induction happened because the woman and/or her health care provider chose to induce labor.

Many women and health care providers opt for elective labor induction. In fact, it may be a factor in why the latest CDC statistics show a 140% increase in the rate of labor induction between 1990 and 2007. Elective labor induction may seem like an attractive option when a woman is uncomfortable near the end of her pregnancy or is trying to plan for a vacation or important event. One study showed that most women don’t perceive labor induction as a safety hazard even at just 37 weeks of pregnancy.

But here’s the rub: researchers estimate that 20% of cesarean births among the women studied could be attributed to labor induction. After adjusting for confounders, for example, obesity and high blood pressure, labor induction was associated with a two-fold increase in the risk of cesarean birth.

Researchers also found a significant association between obesity and risk of cesarean birth. What do you think? Could the answer to reducing our 31.8% cesarean birth rate be reduced by a healthy lifestyle and avoiding unnecessary induction of labor?

For more information on when to allow labor to start on its own and when labor induction is medically necessary, check out the Journal of Midwifery & Women’s Health “Share With Women” handout on induction of labor.

Pregnant? This Caffeine Shot is for You…Maybe

by Melissa Garvey, ACNM Writer and Editor

The American College of Obstetricians and Gynecologists released a Committee Opinion this month entitled Moderate Caffeine Consumption During Pregnancy. The Committee Opinion examines a long-standing debate: is maternal caffeine consumption related to spontaneous miscarriage?

Caffeine raises a woman’s levels of catecholamines—hormones released into the blood in response to stress—and crosses the placenta to her unborn child. Sources of caffeine include coffee, tea, soft drinks, and chocolate.

Most studies on the relationship between caffeine and miscarriage have significant limitations, including small sample size and recall bias. The new Clinical Bulletin explores the results of several recent, higher-quality studies. The good news is that they found no link between moderate caffeine consumption and miscarriage. However, the results regarding higher levels of caffeine consumption are not black and white. The Committee Opinion states:

“Moderate caffeine consumption (less than 200mg per day) does not appear to be a major contributing factor in miscarriage or preterm birth. The relationship of caffeine to growth restriction remains undetermined. A final conclusion cannot be made at this time as to whether there is a correlation between high caffeine intake and miscarriage.”

Nutrition research can be especially challenging due to the difficulty of isolating various nutrients and controlling for confounding factors. For example, are the women consuming large amounts of caffeine in these studies getting a good night’s sleep? Are they using caffeine to keep up with a high-stress job?

What are your thoughts on this Committee Opinion? If you’re expecting, will it change your caffeine habit? Midwives, will this affect the advice you give to your patients and clients?

Midwife Develops iPhone Application for Expectant Parents

by Melissa Garvey, ACNM Writer and Editor

If you’re an ACNM member, you may remember Sandie Mulcrone, CNM, from the Spring 2008 and Spring 2009 issues of Quickening. I first interviewed Sandie after she successfully pioneered her way to a new hospitalist position at Advocate Christ Medical Center in Oak Lawn, IL. One year later, Sandie contacted me to share how she started her own business to improve women’s access to breastfeeding equipment. This summer, she’s at it again with yet another pioneering idea: iBabySono.

iBabySono is an iPhone application that allows expectant parents to store, sort, display, and share their baby’s ultrasound photos via iPhone, Facebook, and other online channels. Parents simply download their ultrasound pictures, then use iBabySono to upload the images and create virtual scrapbooks, calculate baby’s age, post images to Facebook, and send e-mail attachments to friends and family.

“Expectant moms and dads are experiencing one of the most exciting times of their lives,” says Sandie. “This is their future, a little person who represents their hopes and dreams. iBabySono lets them share that excitement and that joy with everyone they love from the earliest possible stages of their baby’s development.”

iBabySono is $2.99 in the iTunes app store and comes with a $10 discount for use at Sandie’s business, Perinatal Home Medical Supply.

What are some of your favorite apps for expecting and new parents or families?

August is Midwifery Advocacy Month: Ten easy and energizing steps to make a difference!

Kathryn Kravetz Carr, CNM, Chair, ACNM GAC

1. Get educated about MOMS 21. Learn how Maximizing Optimal Maternity Services for the 21st Century (MOMS21, HR 5807) will improve maternity outcomes, increase access to care, and curb rising health care costs. Also be sure to visit the new ACNM MOMS 21 Web page.
   
   
2. Check if your representative is a cosponsor (search here to find out). We ALREADY have the support of 30 US Representatives! If yours is a cosponsor, thank them for their support.
   
   
3. Call your US Representative and Senators in their DC office. Find out who your legislators are here, and ask them to cosponsor MOMs 21. Use these talking points as a guide.
   
   
4. Email or fax a letter (view samples here) to your Representative’s and Senators’ Health Legislative Aide in the DC office. Attach the Dear Colleague Letter and the bill info sheet.
   
   
5. Spice it up. Consider including some of these supporting documents: Essential Facts about Midwives, Nurse-Midwifery in 2008, Primary Care Providers, and Evidence-based Maternity Care.
   
   
6. Meet your legislators in their local offices or invite them to your practice. Congress will recess August 9 through September 12. To find their local offices click “contact” at this link. Request a visit using this Senate letter or this Representative letter.
   
   
7. Capture your visit with a photograph. Have your fellow midwives sign the photo, and return it as a thank you gift. Submit the lobby day evaluation form to let us know how it went.
   
   
8. Don’t sweat the details. When you talk with your legislators, their health care staff, and the media, discuss the women you serve and obstacles to better care. Should they have questions regarding the legislation, they can contact ACNM Federal Lobbyist Patrick Cooney at 202-347-0034 or patrick@federalgrp.com.
   
   
9. Involve the Media. Send the MOMS 21 Press Release out, and call your local media. ACNM members, don’t forget to let the Ambassador Toolkit help you out. Let midwives in your community know you reached out, and see if others have personal contacts in the media.
   
   
10. Keep the relationship going! Once you have established a connection with the Health Legislative Aide, maintain it throughout the year with continued communication. Successful advocacy is all about the relationship!
    

For the Love of Midwives: Wilmington Women Launch a Revolution

The following post was written by Where’s My Midwife? in honor of National Midwifery Advocacy Month, which is commemorated each August. The American College of Nurse-Midwives (ACNM) and its Government Affairs Committee encourage all ACNM members and supporters to participate in National Midwifery Advocacy Month. Learn more about advocacy activities here.

One year ago, on August 1, 2 certified nurse-midwives (CNMs) were fired from a Wilmington, NC, private practice, and 80 pregnant women were suddenly left without the care provider of their choice. They had chosen a midwife for very personal reasons, and had grown to know and trust their providers. The physicians at the practice assumed the women would simply start seeing the obstetricians, but they did not understand the type of care midwives provide. Our midwives spend 20 – 30 minutes with their clients at each prenatal appointment; they ask about a woman's personal and emotional well-being because they understand that these factors will have an impact on her labor; midwives stay with a patient throughout her labor and delivery.

The women in Wilmington have little or no choice when it comes to maternity care. There is only one hospital in three counties where women can give birth. After two midwives were fired, there was only one midwife serving our community. This was simply not acceptable. So, we took matters into our own hands. We stood up to the hospital and the physicians and said, “We want to be treated a certain way, and we will not allow you to take away or block our access to the type of care we want.” We successfully got the physicians to change a policy that required a physician to be in-house while a midwife labored with her patient. It was a policy put in place by the physicians who then complained when they had to stay at the hospital! It was absurd—and these types of policies are in place all over the country.

When we first started investigating whether or not this had happened anywhere else, Sylvia did a Google search on “CNMs fired” and after searching for ONE NIGHT came up with the following locations:

This kind of bullying has got to stop. Midwives are in a very difficult position – if they ask their ladies to speak out in support of them, the physicians who collaborate with them may take it as an insult, leading to a strained work environment. The next time you are at a visit with your midwife, ask her how she is doing. Ask her how she feels about her practice. Ask her what you can do for her. It may help prevent another situation like the one we experienced here. It is time to give back to the midwives who give us so much.

In order for the culture of fear surrounding birth in this country to change, women must stand with their midwives and say, “ENOUGH!” Our midwives give us support through one of the most challenging, vulnerable experiences in our lives. We believe we owe it to them and ourselves to stand up to those who would restrict their ability to practice. We believe mothers who have lost their midwife mid-pregnancy need to share their stories so that the people who make these decisions based on financial gain can see the consequences of their actions. We believe that women need to reclaim the power of their body's ability to give birth.

If you have experienced the loss of a midwife, or if you are a midwife who has been restricted in your practice, please contact us. Your story is important. Your voice must be heard to effect change.



The c-section rate in this country has just gone up for the 12th straight year.

Amnesty International has declared maternity care in the US a human rights issue.

The United States ranks 41st in the world in maternal mortality—it is safer to have your baby in 40 other countries.

It is time for change.
It is time for a revolution.

Plug In to Community for a Healthy Pregnancy

by Melissa Garvey, ACNM Writer and Editor

An interesting study from the University of Michigan rolled into the ACNM news alerts this week. It involved 297 African American and European American women through 32 weeks of pregnancy. Compared to women of higher status based on race or education and income, African American women and women of lower socioeconomic status had higher levels of stress and higher blood pressure during pregnancy. However, women who felt a strong sense of community (higher communalism) did not experience these disparities.
Results of the study suggest that a woman’s sense of community is more important for her mental health during pregnancy than ethnicity or socioeconomic status. It also suggests that community can counteract the effect of ethnic minority and lower socioeconomic status on pregnant women’s blood pressure.
There is a catch. Researchers also found that higher socioeconomic status is associated with a higher sense of community—regardless of ethnic background. Let’s face it. Resources—including community—are easier to come by when you have more money.

Look for the study this month in the American Psychological Association's Journal of Cultural Diversity & Ethnic Minority Psychology. To learn more about the effects of communalism on health during pregnancy, you may also want to read a 2007 study in Obstetrics & Gynecology, which found group prenatal care—based on the CenteringPregnancy model created by Sharon Schindler Rising, CNM—is associated with a 33% reduction in risk of preterm birth.
Looking for a way to increase your sense of community? Try connecting online. Here are a couple suggestions. Feel free to add your favorite online community in the comments section of this post.

GivingBirthWithConfidence.org

• Who It’s For: Written by and for real women, this Lamaze International-hosted online community is the go-to place for information and support related to pregnancy, birth, parenting, and breastfeeding.
• Features: Follow several bloggers, including one woman posting regular updates about her pregnancy. The site also features discussion groups and allows members to create their own groups.
  

KeepEmCookin.com

• Who It’s For: Women with high-risk pregnancies or on bed rest.
• Features: KeepEmCookin features online forums, a place to share your story, and links to news and resources related to preterm birth.

California’s Whooping Cough Epidemic: An Opportunity to Reexamine Vaccination Decisions?

by Melissa Garvey, ACNM Writer and Editor

According to state public health officials, California residents are experiencing epidemic levels of whooping cough. With five infant deaths already and nearly 1500 reported cases so far in 2010, California is on track to experience the highest levels of whooping cough in 50 years.

The Fall and Rise of Whooping Cough in America

Whooping cough, also known as pertussis, is a highly contagious, life-threatening infection. In the early 1900s, it was a leading cause of childhood death in the United States. By the 1970s, following the introduction of a vaccine, infection levels waned.

Since the mid-1970s, cases of whooping cough have been increasing—especially in infants too young to have completed their vaccination schedule and in teens and adults whose immunity has expired.

Could Vaccines be Linked?

Some experts are wondering if California’s low rate of vaccination against whooping cough could be a factor in the state’s epidemic. While the state’s rate of adolescent vaccination is above the national average, it falls short of many states who require adolescents to receive the pertussis vaccine (commonly known as Tdap) by law. California legislation currently does not require Tdap.

Given this information, does this change your mind about vaccination decisions for you, your family, or your patients? Does it reinforce your beliefs or encourage you to reconsider your opinions?