Making Mississippi Midwives Illegal

I was horrified to find out that a bill has passed the Mississippi House of Representatives, and was sent to the Senate, to make CNMs the only legal midwives in Mississippi. My state was one of the few that was “alegal” — there was no language specifically protecting or prohibiting non-nurse midwives.

While it’s too late to contact the Representatives (I emailed mine anyway), you can email the Senators and ask them to vote against it. Even if you’re not from Mississippi, I would still appreciate a show of support for CPMs from citizens of other states. There are almost no CNMs in Mississippi anyway — none that I know of in the top half, perhaps the top 2/3 of the state; when I had Seth, my midwife (a CPM) was from Tennessee — I don’t know how that might affect midwives crossing state lines. Currently, CPMs are illegal in Alabama, but some Tennessee CPMs have set up a “birth house” just over the border to accommodate women who don’t want to give birth in the hospital, but live close enough to the border to drive there in labor.

My mind is still reeling — I feel like I’m writing pretty scattered, here — hopefully you can find the coherent thought in it, though.

I have nothing against CNMs — I had a CNM attend the birth of my first baby. This isn’t some sort of turf war — just trying to keep alive the only form of midwifery available in my area.

Please share the word, too, if you will. Thanks!

Update: — I just noticed that some of the email addresses of the Senators are incorrect — two at least are misspelled (one “seante” and another “.us” instead of “.gov”), and one email address was listed as the same address for at least 3 different Senators. Sandra has commented below with a list of email addresses which appear to be correct, so you may want to use those instead. The first list is by district whereas Sandra’s list is alphabetical, so you should probably use one of the other and not both, in order to make sure you get them all.

2nd Update: — if you’re on facebook (and maybe even if you’re not), here is a post I wrote that I hope was a little more collected, outlining why I support home birth. It is what I used as the base for my email to the Senators (mostly changing the end from “please contact” to “please vote against this bill”). Feel free to pass it around and use what you want from it in your own emails if you wish. I don’t know if emails make more impact if they’re similar or if they’re all unique (probably the latter), but if you don’t have time to write a response of your own, I don’t mind if you use portions of what I’ve written and make it your own.

3rd Update: — if you’re on facebook, you can join this group to keep up with what’s going on. If you know of any other groups (large or small, official or unofficial) that are involved in defeating this bill, please let me know, so we can join forces.

Lack of Proof, not “proof of lack”

In my recent post regarding whether or not to legalize midwifery, there was an angle I wanted to explore, but did not have the link in hand. Now I do.

While being a certified professional midwife is proof of having attained a certain level of knowledge and/or practice (much like having a driver’s license), not having said certificate is not necessarily proof that a person does not have the skills necessary to perform in said function.

I know one artist, who was so good that she was not chosen for two different awards. “How??” you might ask. Quite simply, she was too good. In one contest, she was disqualified because they did not believe that she, a 17-year-old, had actually done the drawing herself (and the contest was only open to those under 18). In another contest, her drawing was disqualified because the judges thought that it was a fraud — that instead of it being an actual drawing, that someone has used a computer program to render a photograph in black and white to look like a drawing. [She found out when her mother, without identifying herself as the mother of the artist, sidled up to the judges and pointed to her daughter’s artwork and said, “That one’s pretty good — how come it didn’t place?” Just as an extra kicker, one of the drawings was actually completed in the car on the drive to the contest!]

Here is the link to her online portfolio. Yeah, she’s that good! (Go check it out, and tell me what you think.) Most of these drawings were done when she was 18, a few when she was 19. When I asked her for the link, she said that she ought to update it, since the pictures there are from 2002-2003. [If you’re interested in getting her to draw a portrait, she said the prices were very negotiable.] This one is actually my favorite for a few reasons. First, I know the subject — the youngest daughter of my late pastor; and secondly, it shows part of her skill a little better than the others, in that she alters the pose, rather than just doing a carbon copy of the photograph. She’s just incredible.

But, she is missing a few “gold stars” in her portfolio, in not having won those awards as a teenager. Yet that is most certainly not “proof of lack,” any more than not being certified (whether as a midwife, doula, piano tuner, or any other profession).

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Mary Breckinridge, the first American CNM

At a time when maternal mortality was 800/100,000 and infant mortality claimed one in ten lives, Mary Breckinridge was a true life-saver. She established Frontier Nursing Service in 1925, which brought quality care to rural (and typically, impoverished) Kentucky women. Frontier still trains nurse midwives. Here are a few articles about Mary Breckinridge, in honor of National Midwifery Week:

In many ways, Ms. Breckinridge was to nurse-midwifery what Ina May Gaskin is to non-nurse midwifery. Most of us are probably more familiar with Ina May than Mary Breckinridge, for many reasons — we home-birthers tend to hire CPMs rather than CNMs (who many times cannot legally attend home births); we’ve read her engaging books; she’s still alive and giving interviews, and working hard promoting midwifery and awareness of maternal mortality, etc. But there are many similarities between the two women — both saw a need and filled it; both popularized midwifery; it’s possible that without Mary Breckinridge, there would be no “CNM” at all, and perhaps without Ina May Gaskin there would be no CPM either. There have been many other influential figures, and many other necessary players, in the realm of midwifery; but in each of these cases, they were at least the starting point in their respective fields, and in so doing, saved midwifery and/or home birth. In some ways, Ms. Breckinridge had a harder role, perhaps, living at a time when doctors were on a full-court press to eliminate midwives as dirty and incompetent (in contrast to their sterile hospitals and/or sterile technique, in addition to their high-falutin’ education). The fact that maternal mortality increased with the increase in hospital births was not widely known; and the fact that these “dirty” and “incompetent” midwives had lower maternal mortality attending home births than doctors attending home births; and home birth had lower maternal mortality (and morbidity) than hospital birth, was actively suppressed by obstetricians of the day, in their PR campaign to drive out midwives and midwifery. For a woman to consciously and willingly step into a demonized role, roll up her sleeves, and get to work, should be recognized and given full credit. In some ways, I think it might be like the wife or daughter of a plantation owner going to live in a slave hut, and working the fields, instead of living a pampered life of ease and enjoyment.

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Article on Ina May Gaskin

From the UK, click here to read it. A couple of quibbles — the author says that in 24 states it’s illegal to have a home birth. That’s not exactly true — 24 states do not have legislation allowing CPMs to practice; but of those 24, some are legally restricted, while others are in a legal gray area (“alegal”, not “illegal”). Still, women can choose to stay home and give birth with a midwife, however the midwives may be subject to prosecution for attending said birth. Also, most hospitals do not have pubic shaves & enemas as standard (which the article implies, at least for one hospital), but I have heard a few things here and there about them still being offered or suggested even in the past 5 years.

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?

Birth wars

This post is a must-read for everyone. I won’t comment on it, so as not to detract from it, nor to take any extra time — except to say, it’s from Australia, so aside from a few things that pertain strictly to that country, it could be written about America. Just go read it. Here’s a teaser:

YOU’RE in the dentist’s chair with a painful tooth, feeling fragile.

“That tooth has to come out,” says the dentist.

“I’ll give you an anaesthetic and extract it.”

You’re surprised – you had hoped the tooth would be all right – but you nod and say something like “Ungh-hnghm” through a mouthful of cotton wool and dentist fingers. After all, he’s the expert.

The dentist turns to prepare the needle, when a dental technician leans over and whispers in your ear: “You know you don’t have to do what he says.

“He doesn’t know what he’s talking about. What about root canal? Or homoeopathic remedies? And anyway, you don’t need an anaesthetic.

“There’s a dentist next door who does acupuncture and hypnosis for pain relief. It’s much safer. Oh, and did you know fluoride is toxic?”

The dentist snaps at her to stop: “Ignore her – she’s pushing her own agenda.”

Tense, stressed and utterly confused, you lie back, open your mouth and look up at two medicos glaring at one another.

Who is in charge here? What’s the real truth? And why didn’t anyone tell you there was some sort of power struggle going on?

Of course, this doesn’t happen in dental surgeries. Open hostility between clinicians would be madness, serving only to baffle patients and undermine the whole purpose of creating healthy smiles.

But this is exactly what happens in maternity care, every day, in birth centres, hospitals and homes. Hostility, suspicion, mistrust, abuse and vitriol abound in relationships between obstetricians and midwives, clinicians, academics and activists.

h/t to Sidney Midwife for the link

Wanna save the nation $9,000,000,000?

Thanks to Gloria Lemay for the original link.