Birth Services

Joyce Kimball, CPM

In October 2016, the Diane Rehm show discussed a recent study regarding the increasing U.S. maternal mortality rate.

I listened and took some notes, below, but here’s what shocked and saddened me:

  1. The rate of maternal mortality in the U.S. is much higher than in other countries. In Britain the maternal mortality rate is 6.7%/100,000 live births; in Germany 4.1%/100,000 in Japan and Canada 6-8%/100,000. In the U.S. it’s 23.8%/100,000 live births!

  2. Of the maternal death rate, 2 out of 3 maternal deaths are associated with cesarean section. 1 out of 3 are associated with childbirth.

We need to stop inducing, augmenting and cutting women.

My notes from the Diane Rehm show: In Texas the maternal mortality rate doubled from 2010 and 2012, similar to the rate of a developing country rate. 17.1/100,000 in 2000 to 35.8/100,000 live births in 2014! The overall maternal mortality rate increased 27% for 48 states from 2000 to 2014. However, in California, the maternal mortality rate has declined.

The maternal mortality rate is the number of women who die as result of complications of pregnancy and childbirth; the death is related to pregnancy or childbirth. In U.S. suicide, accidents, and homicide are not included in the maternal mortality rate. In other countries suicide is included due to the impact of postpartum depression and psychosis.

The rate of maternal mortality in the U.S. is much higher than in other countries: in Britain 6.7%/100,000; in Germany 4.1%/100,000 in Japan and Canada 6-8%/100,000 ; in the U.S. it’s 23.8%/100,000 live births.

So why? Reporting differences in the U.S.? No. Population differences? No. Older? No. Higher rates of chronic conditions such as diabetes and hypertension and obesity? No. Higher access to care in other countries? Yes. Increase in medical procedures such as cesarean section, induction and augmentation? Yes. Mandatory review of all maternal mortality cases? Yes, in other countries. Only a few states have a maternal mortality case by case review. California created a mortality task force and decreased their maternal mortality rate by finding root causes, creating protocols and affecting change.

Top 2 reasons why women die: hemorrhage and hypertensive complications like pre-eclampsia. However, hemorrhage and hypertension rates have stayed the same since 2000 and not increased.

There is a surgical expansion in the care of women, most specifically cesarean section. Cesarean rates are high in U.S. Delivery by cesarean section is relatively safe but can result in many complications especially in subsequent pregnancies. Cesarean section has risks of hemorrhage, infection and death. And if a woman has a cesarean section, she has a higher risk of placenta accreta and uterine rupture in subsequent pregnancies. There used to be interest in VBAC but that interest has faded. The new focus is on preventing the first cesarean section. What created the rise in cesarean section? It’s a relatively of low risk surgery if it’s scheduled. It’s more expensive. But it’s longer recovery. And has higher risks in future pregnancies. The cesarean section rate in the U.S. is higher than most European countries. Of maternal death rate, 2 out of 3 maternal deaths are associated with cesarean section. 1 out of 3 are associated with childbirth. Should doctors discourage cesarean sections? Doctors should have a good discussion re: optimal birth method. "For low risk moms and healthy babies, an uncomplicated vaginal delivery is the safest delivery route for mom and baby."

The proposed midwifery bill “An Act Relative to out of hospital birth” HB#1189/SB#1206 says that there will be an ACOG ob/gyn on the board of midwifery. "Section 261...board members shall be...a licensed physician who is an obstetrician certified by the American Congress of Obstretrics and Gynecology and who has had professional experience working with Certified Professional Midwives;..."

There is no midwife on the American Congress of Obstetrics and Gynecology (ACOG) board

In April 2017, ACOG wrote the following about home birth. ACOG “considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth”. This group of men at ACOG have determined that women who are pregnant with twins or a breech baby or have had a prior cesarean should not have a home birth.

ACOG tells ob/gyns, “Women inquiring about planned home birth should be informed of its risks…a more than twofold increased risk of perinatal death (1–2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4–0.6 in 1,000)” using the flawed methodology (questionable sensitivity analysis, flawed odds ratio, 20+ year old studies used) of the Wax study - and

99% of ob/gyns have not attended a home birth. In 1985 Leigh vs. Board of Registration Massachusetts case law determined that the practice of midwifery is not the practice of medicine. In most cases, ob/gyns' medical malpractice insurances and contracts with their hospitals do not allow ob/gyns to attend home birth, even if they wanted to.

Why would home birth midwives have an ob/gyn on a midwifery board? Why would the female profession of midwifery want or need the approval, permission or guidance from a person employed in a traditionally paternalistic, authoritative institution who has not attended a home birth or worked as a home birth midwife?

If you want to license midwives, ok. But the proposed legislation, “An Act Relative to out of hospital birth” HB#1189/SB#1206 invites a fox in the hen house. Stop HB#1189/SB#1206. 

If you want to license home birth midwives, ok. But the proposed legislation "An Act Relative to Out of Hospital Birth" House bill # 1189, House docket # 1240; Senate bill # 1206, Senate docket # 567 has non-midwives choose the board of midwifery that will "develop rules and regulations" on home birth midwives and families who choose home birth.  
The proposed legislation says that board of midwifery is "Section 261: ...shall be appointed as follows: the governor, …the governor shall consider the joint recommendations of ORGANIZATIONS REPRESENTING CERTIFIED PROFESSIONAL MIDWIVES AND CONSUMERS OF CERTIFIED PROFESSIONAL MIDWIFERY in the commonwealth. ... (c) Any member of the Board may be removed by the governor for neglect of duty, misconduct or malfeasance or misfeasance in office after being given a written statement of the charges against him and sufficient opportunity to be heard. Upon the death or removal for cause of a member of the Board, the governor shall fill the vacancy from a list of nominees PROVIDED BY BAY STATE BIRTH COALITION or its successor organization for the remainder of that member’s term.”

If we are going to license home birth midwives and develop rules and regulations on home birth families choices in Massachusetts, why aren’t the Massachusetts home birth midwives providing the recommendations to the governor? We have a well-established, long-term professional trade organization here in Massachusetts - The Massachusetts Midwives Alliance (MMA). The MMA was created in 1984 “by and for a dynamic and diverse group of midwives. The MMA was founded to build cooperation among midwives, and to promote midwifery as a means of improving health care for women and their families.” Bay State Birth Coalition was created in 2015 with the purpose of licensing home birth midwives. Since I have opposed this proposed legislation on home birth midwives, would I be unable to be nominated to be on the Board of Midwifery? Why is a non-midwifery organization choose the nominees for a board of midwifery?

Licensing home birth midwives may be coming, but this bill, as written, is harmful to home birth midwives and the families who choose home birth. 

From the licensing and regulation of American granny midwives out of existence, to the Skype midwives, traveling midwives, women who birth unassisted, and women who cross state lines to birth with whom and how they want, there is 100 years of evidence that licensing midwives restricts women’s birth choices.

The evidence shows that the 2000 term breech study was flawed and vaginal breech birth should be an option.

The Maine compromise was not a pause; it was acquiescence to make it “politically palatable” to the Maine Medical Association and the Maine nurse midwife association due to the pressure the MMA and Maine chapter ACNM was getting from their national organizations. Now HBACs are not allowed, per statute in Maine.

I looked at every state’s licensing laws. 23 of the states that license have severe restrictions (everything from required physician permission to home birth to no HBACs to only certain types of midwives can attend home birth to required vaginal exams, required testing, required transfer if woman doesn’t “progress” according to the state, to outright making home birth midwifery illegal, etc.) on a woman’s right to choose. These states are: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Indiana, Louisiana, Maine, Maryland, New Hampshire, New Jersey, New Mexico, New York, Rhode Island, South Carolina, Texas, Utah, Vermont, Washington, Wyoming.

No state has rescinded nor lessened their restrictions. Only Minnesota, Montana, Virginia, and Wisconsin license midwives without restricting women. 13 states do not license midwives and therefore do not restrict women’s choices - Connecticut, Hawaii, Kansas, Massachusetts, Mississippi, Missouri, Nevada, North Dakota, Ohio, Oklahoma, Oregon (voluntary licensure), Pennsylvania, Tennessee. 7 states do not license but make home birth midwifery illegal - Alabama, Illinois, Iowa, Kentucky (no permits given since 1975), Nebraska, North Carolina and South Dakota. Michigan just licensed and rules and regulations have not yet been written. West Virginia is licensed but I couldn’t find their regs.

It is educational elitism to require trained, experienced, educated home birth midwives to complete additional expensive unnecessary education. Requiring additional education was just one way that the U.S. regulated “dirty” and “uneducated” granny midwives out of existence. Additional education does not make birth safer. Additional education means that poor women can’t access midwifery as a career choice to serve their community.

As Autumn Vergo wrote, “Refusal to accept that safe practice may mean turning some clients away is a factor in keeping midwifery unintegrated with the rest of maternity care.” I accept birth. I accept that words “safe practice” means “practice the way the state wants a midwife to and not according to a mother’s wishes.” I accept that turning women away by declining their birth choices sends them to either the often abusive hospital system or to unassisted childbirth. I accept and I’m ok with home birth midwifery not being integrated with hospital midwifery care.

By restricting a woman’s right to choose, we end up with court-ordered cesareans. While I may not agree to attend a woman having triplets at home, it’s her choice. It’s not “some” clients who are restricted by criminalizing home birth midwifery. It’s every woman who has her health choices restricted. When the state determines that they know better, women have lost their childbearing rights.

As a home birth midwife I am fully integrated with the maternity care system. I collaborate daily with all aspects of the maternity system and have transferred smoothly to the hospital about 100 times in 15 years. I don’t need a piece of paper to develop deep, trusting relationships with my community maternity care system. Nor do I need a license to transfer smoothly and professionally.

I do not agree that “midwifery is accessible to practitioners who choose to be socially and financially marginalized…privileged.” I am not, nor are the midwives I work with privileged nor socially or financially marginalized. I do agree that expensive, required, elitist education makes midwifery a privileged and financially marginalized career, out of reach for poor women.

I have students of all kinds shadow me for days – all types of residents, lab techs, paramedics, nurses. Every practitioner in the room can watch how I support a woman’s right to informed consent/declination. I do not need a piece of paper to model the midwifery model of care.

My community is Massachusetts. My clientele is mostly urban and rural middle class and poor. It includes young and old, white and women of color, super wealthy and homeless. Home birth midwifery needs marketing, not restrictions.

I see no benefit to licensing; only harm to midwives and human rights violations to women. As Nikki Chamoy said, “Making certain women’s health choices illegal has never improved women’s health.” Why oh why would women agree to legislative restrictions on their bodies?

Keep your laws off my uterus.