Legal, illegal, or alegal; certified or noncertified?

Certified Nurse-Midwives can legally attend births in all 50 states (although not all can attend out-of-hospital births, due to various rules, regulations, legislation, or just plain politicking); Certified Professional Midwives can legally attend births in 26 states, with the remaining 24 states either outright making it illegal for them to attend births, or just not having statutes on the books one way or another (or they’re too vague). Some have noted that if non-nurse midwives (including certified as well as non-certified midwives) do not have legal protection, then they may be charged with practicing medicine (or midwifery) without a license, facing fines or even jail charges.

Many midwifery proponents advocate for changing the laws in the remaining states to make CPMs (or perhaps non-certified midwives as well) legal birth attendants, specifically, rather than relying on the gray area for protection. Not all do, though. Through the years, I’ve read numerous things on the subject, both for and against certification, with those against noting the potential downsides. I was made to think on this subject again with Gloria Lemay’s post. One of the things she notes is that legal midwives are often restricted from being truly autonomous, with the case in point of Canadian home-birth midwives being required to play by the rules dictated by doctors, including trying to jump-start labor at 41 weeks (by stripping the membranes), so these women could still qualify for a home birth, because otherwise they’d be induced at 42 weeks.

Molly at Citizens for Midwifery gives her thoughts, in this post, also linking to Gloria’s post, as well as a few others.

I favor certification for a few reasons — although I will admit that it is not without some reservations.

For one, it will standardize midwives, and I do think there are probably some midwives who need to be brought up to standards. How many there might be, I could not say, and without regulation, there is no way to know whether a midwife is qualified or not. Much like a driver’s license does not make you a good driver, but is merely an indication that you have passed a certain standard. In those states that do not have clear rules, midwives may be subject to prosecution anyway, and midwives would not have to become certified if they still wanted to operate outside the law. This may put them at a greater risk of prosecution, but it might not (if their position was uncertain or actually illegal before, then it wouldn’t seem to change much to continue to operate illegally); and it would certainly lower the risk of prosecution for midwives who did play by the rules. The downside, of course, is that “the rules” may be changed. I think this happened in Utah in the past year or two — midwives were first legalized, and then in a subsequent legislative session, a bill was at least under discussion, if not actually passed, to tighten the restrictions for births midwives could legally attend, including no VBACs, and no births where the mother had previously given birth to a child under a certain weight. So, if a mom had had a preterm birth at 30 weeks, regardless of the reason, or if she gave birth to two small twins, and then carried another child to term — despite the fact that this baby and this pregnancy were normal and non-eventful, a midwife would be legally unable to attend her birth. Or, the rules may not be evidence-based, or may be otherwise too restrictive. Also, Australian home-birthing has been undergoing some serious problems, with the legislature essentially writing a law making it illegal for midwives to attend home births (due to insurance regulations and restrictions). While it appears that that has been tabled, or at least is still under serious discussion and hopefully some renovation, midwives who attend home-births without insurance will be stripped of the legal title of midwife for the first “offense”, and then a subsequent “offense” will have them subject to a $30,000 fine and possibly jail time. However, in America, midwives may be subject to a fine and jail time in certain states now, even though they could be certified and legally practice in other states. So, I think on balance, it is better to at least have that as an option.

Certainly, government regulation can be a two-edged sword — giving with one hand while taking with the other. But it would be proof of meeting a standard, and we don’t have that now.

Without a standard and/or certification, a woman may hire someone who is truly not qualified to be a midwife, but she may not know that. If a woman calls herself a midwife, even though she has no training or very little training, mothers may assume that she is well-qualified, or has passed certain rigorous standard or testing, and/or has studied extensively. One midwife I read about said that she began attending births after some women found out that she had had a home birth (probably an unassisted birth), and asked her to attend their births. She did not mention any form of education about birth, except having given birth to her own children. While on one hand I can say, “As long as the mothers knew her skill/education level, then that’s fine”; on the other hand, I have to wonder/worry if other women may not know and just assume that she has the training of certified midwives. Often, women don’t know what to ask about, when interviewing a care provider — either just going with whoever is covered by their insurance, or assuming that all OBs are the same, or just are unfamiliar with the wide variation in practice styles of care providers (high vs. low rates of episiotomies, C-sections, etc.). The same may apply to midwives, as well, with women making assumptions based on a title.

Another factor on legality is that illegal midwives may be hesitant to transfer, fearing prosecution. This may end in higher morbidity or mortality for babies.

There is a lot that could be said on this topic. A lot of positives and negatives could be given about certification. I’m not dogmatic about it, and can be friends with people of differing opinions. What are some of your thoughts?


C-sections and postpartum infections

With “women of size” being more likely to have C-sections (I’ve read one nurse who said she can’t remember seeing a vaginal birth in a woman weighing over 200 lb. pregnant), and C-sections causing more postpartum infections than vaginal births, Well-Rounded Mama has written an important and salient post.

For what it’s worth, I weighed more than 200 lb pregnant both times I gave birth — uncomplicated vaginal home births. Maybe some doctors need to stop blaming “fat women” as a reason for C-sections, and start realizing that “increased risk” does not equal “certainty.” Perhaps some women just need more time to dilate before being rolled out to a C-section. Sure, some overweight women will need C-sections, and perhaps will need them at a greater rate than women of normal weight; but it bothers me that it seems that some doctors have a self-fulfilling prophecy when it comes to C-sections. I think they jump the gun at times.

Who can you trust?

This article doesn’t have anything specifically to do with birth, but is instead about knee replacements. However, it tangentially affects every medical decision in this country. The FDA has admitted that it approved a knee replacement device that doesn’t work. The agency’s scientists said it didn’t work, but approved it anyway. It was a political decision, not a medical decision. You see, the New Jersey company that made the device gave contributions to the state’s two Senators and Representatives, who then put pressure on the FDA to approve the device.

In a new report, FDA cited pressure from senators Robert Menendez and Frank R. Lautenberg and representatives Frank Pallone Jr. and Steven R. Rothman as a decisive factor in gaining approval: “The Director of FDA’s Office of Legislation described the pressure from the [Capitol] Hill as the most extreme he had seen and the agency’s acquiescence to the Company’s demands for access to the Commissioner and other officials in the Commissioner’s office as unprecedented in his experience.”

As Marty McFly said in Back to the Future, watching a model of the car he will be riding burst into flames, “You’re not instilling me with a lot of confidence, Doc!”

It makes me wonder what other decisions have been made — by the FDA as well as others — that were likewise not based on the facts.

You Have a Choice

Click here to go see the video, a short documentary. The thing that I remember most is the nurse at the beginning, talking about the standard assembly-line procedures they do when a woman in labor comes to the hospital. So mechanical; so rote.

Abortion and Preterm Birth — a new study

Sidney Midwife, one of the blogs I read, had this as her most recent post: Study Showing Abortion-Premature Birth Risk Points to Cerebral Palsy. Since this is National Infant Mortality Awareness Month, and since premature birth increases infant mortality, this newest study has implications for this topic.

When I read about the study, I read the article, and then decided to find the abstract. Since the article mentioned that the study was published in the BJOG, and mentioned the study’s lead author, I had a good head-start. So, I went to the BJOG website, did a search for the author’s name, and came up with a pod-cast. Then the abstract. Then — wishful thinking! — I clicked on “fulltext,” fully expecting to go to a login screen, where I would have to pay $38 to view the report. What a pessimist realist! But, lo and behold, the full study is available! [Yeah, I’m a nerd — excited about being able to read a full study. :-)]

Here is the abstract:

Background History of induced termination of pregnancy (I-TOP) is suggested as a precursor for infant being born low birthweight (LBW), preterm (PT) or small for gestational age (SGA). Infection, mechanical trauma to the cervix leading to cervical incompetence and scarred tissue following curettage are suspected mechanisms.

Objective To systematically review the risk of an infant being born LBW/PT/SGA among women with history of I-TOP.

Search strategy Medline, Embase, CINAHL and bibliographies of identified articles were searched for English language studies.

Selection criteria Studies reporting birth outcomes to mothers with or without history of induced abortion were included.

Data collection and analyses Two reviewers independently collected data and assessed the quality of the studies for biases in sample selection, exposure assessment, confounder adjustment, analytical, outcome assessments and attrition. Meta-analyses were performed using random effect model and odds ratio (OR), weighted mean difference and 95% confidence interval (CI) were calculated.

Main results Thirty-seven studies of low–moderate risk of bias were included. A history of one I-TOP was associated with increased unadjusted odds of LBW (OR 1.35, 95% CI 1.20–1.52) and PT (OR 1.36, 95% CI 1.24–1.50), but not SGA (OR 0.87, 95% CI 0.69–1.09). A history of more than one I-TOP was associated with LBW (OR 1.72, 95% CI 1.45–2.04) and PT (OR 1.93, 95% CI 1.28–2.71). Meta-analyses of adjusted risk estimates confirmed these findings.

Conclusions A previous I-TOP is associated with a significantly increased risk of LBW and PT but not SGA. The risk increased as the number of I-TOP increased.

To be honest, the study does not even mention cerebral palsy, nor does it mention infant mortality — those are conclusions drawn by other readers of the study, based on the known facts of the risks of preterm birth and low birthweight. For instance, this cerebral palsy website says, in part,

Extremely low birth weight infants are 100 times more likely to develop CP than a full term infant. In one large overview of 6399 very low birth weight children that survived neonatal intensive care, childen that were evaluated up to age 3, the rate contracting CP was 77 per 1000. 2.5 per 1000 is the normal rate.

The CDC says,

Being born preterm is the greatest risk factor for infant mortality (death within the first year of life). Recent analyses of infant death data by CDC researchers demonstrate that preterm-related deaths accounted for more than 1/3 of all deaths during the first year of life, and more infants died from preterm causes than from any other cause.

Thinking of this sad topic always brings to mind a woman’s blog I read over a year ago. I forget how I even stumbled across it — some word search on Google or WordPress or something. Anyway, she told the story of her pregnancies. Midway through her first pregnancy, she found out that the baby had some defect of some sort — I can’t remember what it was, if it was genetic like Down Syndrome or physical like spina bifida  (probably neither one; it may have even been lethal) — and chose to terminate the pregnancy, rather than to give birth to a deformed child. The abortion took place sometime around 20-24 weeks. Then she got pregnant again; tests showed that everything was fine for this baby, and then a few weeks of gestation after the time of the first abortion, she went into preterm labor that was not (could not be?) stopped, and her baby died. I wondered at the time if her first abortion caused (or at least was a factor in) the early birth of her second baby — that her body having been forced to open too soon for the abortion (an induction abortion, I think, rather than a D&C or D&X), was traumatized by it, and opened too soon during the second pregnancy. This study strengthens that thought. I wonder if women are given true informed consent prior to undergoing abortions, that if they have an abortion, they might later put a wanted child at risk of preterm birth, cerebral palsy, or even death.

Here is a good article that includes more information on preterm birth, including other causes and factors.

But it was just…

NavelGazing Midwife has written a thought-provoking post on birth trauma and birth rape.

One thing that stood out to me (probably because of the recent posts “At least you have a healthy baby” and “You should be grateful“) was the discussion of trauma in the setting of societal norms. In part,

Is Postpartum Post-Traumatic Stress Disorder (PPPTSD) an illness of luxury? If we were huddled in a migrant camp, would we really be concerned that the doctor pushed our legs apart to do a vaginal exam? Or would the multi-rape experiences overshadow the minimal intrusion the roaming doctor or midwife does.

Is PPPTSD judged by societal norms?

When I was in sexual assault self-help groups (almost always led by therapists), there was a tendency among the women to rate the abuse, almost always minimizing their own. “Well, I was just sexually abused at twelve from the guy next door. She was six and it was her brother. She had it much worse than I did.” Over and over, we had to remind each other (and be reminded) that rating the abuse discounted our own.

This is one of the angles I was searching for — maybe I hit on it well, maybe not — in those posts. If we compare outcomes, results, feelings, failings, etc., we will probably find that we are both better off and worse off than others — comparatively speaking. But should we compare ourselves with ourselves? That’s not wise. If we compare ourselves and our situations with how good they could be, we can always find something lacking. If we compare ourselves and our situations with how bad they could be, we can always see that it could be worse. But does the fact that we are not the lowest of the low mitigate the fact that we are in some way suffering and/or in pain? Why should we compare the level of violation we feel to what someone else “must feel” from having been violated in a different way? Is that helpful? If it is, then perhaps we should; but I don’t think that it really is helpful.

In one way, it is this “comparative way of thinking” that may embolden some people to continue acting in a hurtful way. “Well, sure, I did X, but at least it wasn’t as bad as what this guy over here did!” Using that criteria and logic (or illogic), a mass murderer could justify himself by saying, “At least I didn’t murder millions of people, like Hitler and Stalin did — I only raped and murdered 50 women!” ?!?!?!? “Well I may have raped 10 women, but at least I didn’t molest any children!” ?!?!?!? Are comparisons really even valid, when you’re comparing a rotten apple to a rotten orange? They’re both rotten fruit! — why try to make it sound like either one is acceptable?!

One of the first comments on NGM’s post was from Rixa:

Pain (or suffering) is like a gas: it fills the available space, no matter how small or big.

Let Labor Begin on Its Own

Science and Sensibility is having a blog carnival on the Six Healthy Birth Practices, starting, quite naturally, with the first, which is Let Labor Begin on Its Own. Of course, there are sometimes reasons why labor should be induced, or skipped altogether and the woman given a C-section; but primarily it is best for both mom and baby for labor to begin on its own.

Some months ago, I read a blog or article or email about induction, and the author used a phrase that really struck me between the eyes. We know a lot about pregnancy, fetal development, labor, and birth, but we’re still a little fuzzy on what exactly starts labor — some complex interaction between baby and mother, with it seeming that the baby starts labor by some hormonal or chemical signal to the mom that he’s ready to live on the outside. Now comes the poignant phrase. Until the time that labor naturally begins, attempts at inducing labor are more likely to fail because the mother’s body is protecting the baby from being born too early. When an induction “fails” it is because the mother’s body is succeeding at gestating her baby a little longer (probably for his own good). Now, that’s a different way of looking at things!

One childbirth educator I know had two students due about the same time. One or both were being threatened with induction, and the educator was more concerned about one than about the other, because the second woman had a cervix that was far more “ripe” than the first woman, who was barely dilated or effaced at all. However, what happened was that the first woman went into labor prior to her scheduled induction, and had a smooth labor and birth; while the second woman was induced, and had a long, hard, highly-medicated labor, perhaps ending in a C-section. Which shows the importance of naturally going into labor. If judging solely on Bishop’s Score, the second woman should have had an easier labor and birth, because she had a “head start” on the other woman, judging on dilation, effacement, and other signs of a ripe cervix and “labor readiness.” But her body and her baby knew better.