Need More Midwives

Recently, Florida’s birthing atmosphere has experienced a major epidemic. Due to the rising costs of medical malpractice, OBGYNs are increasingly nitpicking patients in order to decrease their chances of litigation and maximize their profits. Some OBGYNs are even discontinuing practicing obstetrics simply because it carries too many risks of litigation and not enough compensation. Medical students are afraid to go into the obstetric field because they’ve heard all the bad stories surrounding medical malpractice suits and insurance premiums. For more details on this issue, you may read the article “More S. Florida obstetricians stop delivering babies” in the Sun Sentinel (http://www.sun-sentinel.com/news/local/palmbeach/sfl-flpobgynpnapr14,0,6542600.story).

Enter midwifery. Two midwifery schools here in Florida are the Florida School of Traditional Midwifery in Gainesville and the International School of Midwifery in Miami. However, more programs are being offered in other locations around Florida as the need arises for more midwives. For starters, did you know that midwives can offer care to many patients who currently see OBGYNs? If patients began seeing midwives, more OBGYNs could get back to their basis of their practice – caring for high-risk pregnancies. Not only would this take pressure off of the obstetricians, but this would also offer many women the wonderful opportunity to experience the midwifery model of care. You can read more about the midwifery model of care at the Citizens for Midwifery website (http://cfmidwifery.org/mmoc/index.aspx).

Midwives come in a variety of settings and types. To start with, midwives practice in hospitals, birthing centers, and even your own home. Depending on your wants and needs, a midwife can definitely accommodate your desired location. Next, midwives in Florida practice as either Licensed Midwives (LMs) or Certified Nurse Midwives (CNMs). Much in the way you would choose among a Family Practitioner, Obstetrician, Perinatalogist, or Maternal-Fetal Specialist, you have a choice of what type of midwife you’d like to attend your birth. An excellent explanation of the differences among these types of midwives can be found here (http://www.naturalbirthandbabycare.com/midwives.html). This source also cites the wonderful fact that midwives can care for more than just low-risk patients. Even women with prior c-section deliveries can receive care from a midwife.

As far as becoming a medium or high risk patient, it is still very possible to receive both prenatal care from a midwife and visit a specialist for whatever may ail you. For example, having gestational diabetes does not necessarily risk you out of a midwife’s care – she can simply send you for visits with a perinatalogist from time to time while still maintaining you as a patient. Women with prior c-sections generally do not need a repeat c-section as most causes for the previous c-section do not reoccur in subsequent pregnancies. Many women have gone onto have success homebirth deliveries after a c-section with both mother and baby turning out happy and healthy.

A Reflection on the ACOG Statement on Homebirths

By: Misty M. McGovern, Student Midwife

Much has been said in my community in the few weeks about the recent ACOG (American College of Obstetricians and Gynecologists) anti-homebirth anti-midwifery press release. If you are a member of even just one natural parenting, natural birthing, midwifery or attachment parenting group, you have probably heard plenty of outrage about it. I find this subject to be of the utmost importance to myself and to all other women in this place we call "home". We must assure that women's rights, not doctor's pocketbooks, are protected first and foremost. As women, we have a responsibility to ourselves, and to our sisters and daughters, mothers and aunts, to make our voices heard and to speak up for ourselves and all women in this country and worldwide.

The German philosopher Arthur Schopenhauer (1788 - 1860) once said: "All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." I love this quote, and used it as a tag line in all of my signatures for a very long time. It can be tested against so many things and found to be true. I think back to acupuncture. Not all that long ago, in my lifetime, acupuncture was considered irrational, illogical and irresponsible. Then, it was considered down right *dangerous* by western society. If you used it in place of allopathic medications, you were basically considered to be writing your own death certificate.

Thousands of years of predictable results, even documented results, were not good enough to convince our doctors of the safety and efficacy of the treatment, even when our western lab-made medicines could do nothing more. However, now that the gold standard of double blind studies have "proven" that acupuncture indeed does work, and quite well, attitudes are changing! Now, the acupuncturists, and those who had been "sold" on acupuncture already knew this, they didn't need double blind studies to tell them, just age old experience. Acupuncture is now more accepted in our society, and you can find an acupuncturist almost as easily as you could find a McDonald's! Acupuncture has even been incorporated into nursing textbooks and has turned into a viable (though, granted, not ideal in the eyes of western medicine) alternative or adjunct to western treatments.

The same can be said about homebirth, and midwifery. For thousands of years women relied on other women to help them through their labors and births. It was a sacred event into which men were not welcomed in most societies. Women were empowered with the task of bringing forth life, and allowing the human species to continue on. But at some point in history we relinquished our power to the doctors. Even in the early obstetrical years, properly trained midwives consistently had better maternal and fetal outcomes than did doctors. This fact, though often overlooked by the "professionals", still holds true today.





This brings me back to Arthur Schopenhauer. First, midwifery and homebirth were ridiculed. This began in the late 1840's (possibly quite a bit sooner, depending on who you ask!) when midwifery was looked at as second class care for poor people. When I was in high school in the 1990's, my best friend's aunt had a baby using a midwife. I asked my mother what a midwife was exactly and she replied, "Oh, that's what poor people use to deliver babies when they can't afford a doctor. It's quite irresponsible!" That was all I knew of midwifery until researching it on my own after deciding to have children. Midwives of today continue to battle ridicule!

"...Second, it is violently opposed." This is where I really think we are now. This is part of the reason that I think midwives, midwifery advocates, and women as a whole should both rejoice, and scream even louder in protest as a result of the recent ACOG statement! We are making a difference, and we are causing change. This change is evident in the fact that ACOG and its members feel attacked by midwifery. They feel like midwifery is a threat to their pocket books, and this has them all in a bunch! We must keep them backed into a corner with our superior care of women; our superior maternal/fetal outcomes; our superior cesarean section rates; and our superior breastfeeding rates! We should continue to make them shake in their boots about us, until they finally realize that which we all already know: that competent midwifery care is ideal for the normal, healthy, low risk pregnant woman's care.

Eventually, this will be "accepted as self-evident." To quote ACOG, "The main goal should be a healthy and safe outcome for both mother and baby." We already know that in low risk, normal pregnancy, women that birth with midwives who maintain non-interventive policies fare far better statistically than induction, epidural, lithotomy position, cesarean section happy OBGYNs. We don't need their "scientifically rigorous" studies to prove it to us. The ACOG statement just brings us one step closer to our ultimate goal, which is a total reintegration of the midwifery model of care for women and babies throughout the country, and the world. Let’s take the outrage that we feel boil up from deep in our bellies upon reading the statement and turn it into energy to create positive change. After all, women are strong, and tired of being bullied. We're ready to take back what is ours, one empowered birth at a time.

Choosing A Care Provider

When choosing a primary care provider, we don't ordinarily rush to hire a surgeon to handle our every need. A sneeze does not indicate a necessity for rhinoplasty, nor does a headache always require brain surgery. So why then is it that women are rushing into the arms of surgeons to give birth? Obstetricians are surgeons who go to medical school to specialize in surgical techniques for labors and deliveries gone wrong. It wasn't until the late 19th century that the practice of routine intervention became commonplace, more than likely due to the advent of antiseptics, antibiotics, and anesthesia. Before the popularization of obstetrics, midwives cared for most pregnant women during labor and delivery. Thousands of years of history and experience refined their skills and abilities into what we now know as modern midwifery. The scope of midwifery covers much of the natural processes of pregnancy and childbirth, yielding only to complications in which medical intervention becomes necessary and life saving. Midwives are trained to minimize interventions and respect the natural birth process, which yields better outcomes for mothers and babies.

Midwives practice evidence-based care. "Evidence-based" means using results of the best research about the safety and effectiveness of specific tests, treatments, and other interventions to help guide maternity care decisions. You may be surprised to learn that most maternity care in the United States is NOT evidence-based. Midwives receive training in labor and delivery just as an obstetrician does; however, the midwife is more akin to your primary care physician who refers to a specialist – for complications outside of the general practice scope. In some states, including Florida, midwives receive licensure as well. While we are more likely to hear about cases in which bad outcome are associated with midwife-attended births, those situations most certainly do not represent the majority of such births. The National Birth Center Study (Rooks et al., 1989) found that birth centers were a safe alternative to hospitals for women at low-risk of birth outcomes, and used fewer resources than hospitals did. A systematic review of midwife-led birth centers reached the same conclusion (Walsh & Downe, 2004). Similarly, a recent study of more than 5000 women intending to birth at home attended by Certified Professional Midwives found a similar rate of intrapartum and neonatal mortality rates as in low risk hospital births, but with lower medical intervention rates (Johnson & Daviss, 2005).

Midwife means "with woman." Midwives provide personalized care that respects individual and cultural differences. With a midwife, you become an active partner in your care working with your midwife to decide the course of your pregnancy and birth. Whether you are a first-time mom or a fifth-time mom, a new baby will change your life in wonderful and unpredictable ways. The outcome of a birth is more than a healthy mom and baby – it’s a family. Midwives treat you as a whole person while addressing your physical, emotional, psychological, and spiritual needs throughout pregnancy, birth, and the postpartum period. Remember midwives when you think of pregnancy and childbirth. Healthy, low-risk women have the option of hiring a midwife to care for them during pregnancy. Women have the right to choose what type of practitioner will provide their prenatal care.

The Cesarean Epidemic

The most common operating room procedure in U.S. hospitals, c-section involves considerable morbidity in women and babies and considerable expense for private payers/employers and Medicaid/taxpayers. - Childbirth Connection

The percentage of United States’ births delivered by cesarean section has increased substantially in recent years, climbing 50 percent over the last decade from 20.7 percent of all births in 1996 to a new record high of 31.1 percent in 2006 (1,2). These statistics are featured in a new report released in December 2007 by U.S. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, and are based on data from over 99 percent of all births for the United States in 2006. Consistent with the rise in the national rate, the 2006 C-section delivery rate was 36.0% of all deliveries in Florida up from 22.6% in 1997. In a 2006 report from the Agency for Health Care Administration (AHCA) Center for Health Statistics C-section rates were found to be higher among women of Hispanic ethnicity and among women ages 30 years and older in 2004. South Florida had the highest rate of any region. Of the ten facilities statewide who had the highest cesarean rate six were located in Miami-Dade County. (9) In 2006, the C-section rate for Miami-Dade was a staggering 44.8%. While many experts contend that there is no “ideal” cesarean rate, the World Health Organization (WHO) maintains that in a developed country, the proportion of cesareans should not exceed 15%; beyond that, the maternal injury and death consequent to major abdominal surgery being to eclipse the lives and health saved.(3) More women suffer from infection, hemorrhage and death, and babies are more likely to be born prematurely or die.

There is little evidence that a vast, growing segment of the female population wants or needs major abdominal surgery to give birth. (5) Until the 1940’s, cesarean delivery was rare and only utilized as a last resort to save the baby, many times at the cost of the mother’s life. One in 16 women died. Advances in surgery, antibiotics, transfusions and anesthesia have made an operation that was nearly always fatal as recently as the mid-19th century routine 150 years later. Despite these advances, serious consideration should be given to the risks involved in cesarean surgery. Recent mortality figures from a large study of over 150,000 elective Cesarean operations in Britain show that mothers run nearly three times the risk of dying from a Cesarean section than from a natural delivery. Additionally a woman having a repeat C-section is twice as likely to die during delivery and twice as many women require re-hospitalization after a C-section than after a vaginal birth. (6)

Not only is the health of the mother impacted. Since vital statistics data on cesarean sections was first collected in 1989, the infant mortality in the United States for total cesarean deliveries has consistently been about 1½ times that of vaginal delivery. (7) It had long been assumed that the difference was due to the higher risk profile of mothers who undergo the operation. Many have pointed to changes in the population of childbearing women, such as more older women who have developed medical conditions and more women with extra challenges of multiple births. While there are some overall changes in this population, researchers have found that cesarean section rates are going up for all groups of birthing women, regardless of age, the number of babies they are having, the extent of health problems, their race/ethnicity, or other breakdowns (7). A study of almost six million births published in the September 2006 found that the risk of death to newborns delivered by voluntary Cesarean section is much higher than previously believed. This study, according to the researchers, is the first to examine the risk of Cesarean delivery among low-risk mothers who have no known medical reason for the operation. Study authors used the Healthy People 2010 criteria for low-risk (women with a full-term, singleton infant in head down presentation) and included only women who had no reported risk factors or complications of labor and delivery identified on the birth certificate. (14) Among this group there was a 49% increase in odds of cesarean delivery from 1996 to 2001, after statistical adjustment for maternal age, race, education, birth weight and parity. Researchers found that the neonatal mortality rate for Cesarean delivery among low-risk women was 1.77 deaths per 1,000 live births, while the rate for vaginal delivery was 0.62 deaths per 1,000. The risk in first Cesarean deliveries persisted even when deaths from congenital malformation were excluded from the calculation. (7) In other words, there is a change in practice standards that reflects an increasing willingness on the part of professionals to follow the cesarean path under all conditions.

Despite these cautionary statistics the rising trend of surgical birth persists. The overall increase in cesarean sections is due in large part to a notable rise in primary section rates, from 14.6 percent in 1996 to 29.0% in 2004. This increase is also partly attributable to the decline in Vaginal Birth After Cesarean (usually abbreviated VBAC) at an all-time low of 9.2 percent in 2004. (13)A woman who has a primary cesarean section has a greater than 90 percent chance of having a subsequent cesarean delivery. A policy statement published by The American College of Obstetricians and Gynecologists (ACOG) in 1998 recommended a surgical team and anesthesiologist must be available twenty-four hours a day in order for VBAC to be safe. Many hospitals who fall short of this criteria have been choosing not to allow women to attempt VBACs within their facilities because they cannot provide 'immediate' surgery if needed. A large number of physicians feel that the risks of uterine rupture (developing a tear in the wall of the uterus) that accompany VBAC are too high and that an elective or scheduled c-section is the best option for a mother who had the surgery for a prior pregnancy. Yet evidence is growing that scars in the uterus which accompany cesarean surgery can cause placental abnormalities that endanger both mother and baby in future pregnancies, and that the risk of these abnormalities increases dramatically with a subsequent cesarean. (8) Cesareans are inherently riskier than normal vaginal birth, but repeat cesareans carry even higher risks.

Today, more than ever physicians may be turning to Cesareans sections in order to avoid potential litigation. Under the specter of lawsuits C-sections have gradually become more about caution and convenience than life or death. Many obstetricians contend that patients are driving this trend with their almost unreasonable aversion to even the smallest risk. (4) The tragedy behind this phenomenon is that a cesarean is not a guarantee of a happy outcome. In comparison with other industrialized nations, the United States ranks second-to-last in infant survival and for the first time in decades the number of women dying in childbirth has increased. (10) Some experts cite consumer demand as a contributing factor in the rising cesarean rate. A New York Times article published December, 2007 noted that there was some evidence that a growing number of women were requesting Cesareans. (4) Yet, findings from the large and well-designed United States national study, Listening to Mothers, reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean actually requested one. The survey, conducted by the Childbirth Connection (a leading nonprofit organization that works to improve maternity care), also noted that, in contrast, nearly 10 percent of those surveyed reported feeling pressure by a health professional to have a cesarean delivery, and 42 percent believed that fear of being sued leads physicians to perform unnecessary cesareans (9).

In the US, the profit motive explains may explain rising rates of Cesarean. According to the HealthCare Cost and Utilization Project (HCUP), a 2000 study conducted by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, childbirth accounts for more than four million hospitals stays annually and over $33 billion dollars in aggregate charges in 2003 alone. Many health professionals are feeling squeezed by tightened payments for services and increasing practice expenses. The flat "global fee" method of paying for childbirth does not provide any extra pay for providers who patiently support a longer vaginal birth. Some payment schedules pay more for cesarean than vaginal birth. A planned cesarean section is an especially efficient way for professionals to organize hospital work, office work and personal life. Average hospital charges are much greater for cesarean than vaginal birth, and may offer hospitals greater scope for profit. (11) In the private American healthcare system, doctors and hospitals find cesarean sections more profitable than natural births.

There is no denying that cesareans save lives when performed as an emergency intervention. Many cesareans are the clear result of medical necessity, but others occur in circumstances where there are other options available including many which are medically appropriate. A great majority are performed as a result of a labor that has gone on too long or at the first deviation from the norm, such as a “non-reassuring” fetal heart rate on a monitor. There is an overall lack of support for normal physiological birth evidenced by the dwindling number of women who labor without the assistance of induction or augmentation. A rising number of women are being pushed into the operating room after failed inductions and fetal distress caused by augmentation. (12) The practice of “defensive” medicine, heightened by rising malpractice premiums has created a climate of fear which not only affects the care providers, but the clients they serve. The escalating C-section rate in the U.S. should be a major public health concern. It represents a complex and difficult problem whose solution demands strategies that are multifaceted and comprehensive. Although doctors, hospital, and insurance companies (who often represent warring interests), do contribute to the high rate of cesareans, it is not only with them that blame should be placed. These facts point to a failure in the United States’ system of maternity care. Yet this is not the only issue. The increased rate of cesarean deliveries nationwide may be partly due to a lack of consumer knowledge. Most mothers are healthy and have good reason to anticipate uncomplicated childbirth. Cesarean section is major surgery and increases the likelihood of many short- and longer-term adverse effects for mothers and babies.(1) One primary influence in determining routine care regardless of its proven risks and benefits lies in the perception of birth as a dangerous and life threatening event. Consumers must take a proactive approach to educating themselves about the physiological process of natural birth and the impact of interventions on a woman's ability to birth normally. (15) Education is the key word in preventing unnecessary cesareans and having a safe birth experience. When a cesarean section is necessary, it can be truly life-saving, but birth is a safe and natural process that generally succeeds without intervention.



(1). Childbirth Connection. New National Survey Results from Mothers Refute Belief That Women Are Requesting Cesarean Sections Without Medical Reason. Press release. March 20, 2006.

(2). Declercq E, Norsigian J. Mothers aren’t behind vogue for Cesareans. Boston Globe April 3, 2006.

(3) WHO, Appropriate Technology for Birth; Jose Villar et al., Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America, Lancet 367 (2006): 1819-29.

(4). Bakalar, N. Voluntary C-Sections Result in More Baby Deaths. New York Times Sept 6, 2006.

(5). McCullough, M. C is for caution: C-sections on the rise. Philadelphia Inquirer June, 10, 2007

(6) Hall MH, Bewley S. Maternal mortality and mode of delivery [letter]. Lancet, 1999; 354: 776

(7) Declercq, E, Menacker F, MacDorman MF, Malloy, M, Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk, United States, 1998-2001 Birth Cohorts, Birth: Issues in Perinatal Care 33:3 2006 175-182

(8) Health Outcome Series: Cesarean Deliveries in Florida Hospitals, AHCA State Center for Health Statistics May 2006

(9) Declercq, E. et al., Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences (New York: Childbirth Connection, 2006)

(10) Organisation for Economic Co-operation and Development (OECD) Health Data 2007: Statistics and Indicators for 30 Countries July 18, 2007

(11) Why Does the National U.S. Cesarean Section Rate Keep Going Up? (New York: Childbirth Connection, 2007)

(12) Block, J. The C-section epidemic. Los Angeles Times September, 24, 2007.

(13). Declercq, E, Menacker F, MacDorman MF, Rise in “no indicated risk” primary cesareans in the United States, 1991-2001: Cross sectional analysis, BMJ 2005; 330:71-72.

(14) U.S. Department of Health and Human Services. Maternal, infant and child health. In: Healthy People 2010, 2nd ed. Washington DC: U.S. Government Printing Office, November 2000, pp. 16-30-31.

(15) The Cesarean Epidemic - A Response, Independent Childbirth, 2007

Announcing the Florida Friends of Midwives Website!!!

The website for Florida Friends of Midwives is finally finished! Words cannot express how happy I am.

You may visit the site at - www.flmidwifery.org

We have some Phase 2 and Phase 3 updates planned for early March and April, but for now, the site is done.

MANY MANY MANY MANY MANY MANY thanks to Lori Manning, my best friend of almost 15 years, who is a professional web designer and donated her time to designing the FFOM website. She really came through for me and us and put in over 100 wo-man hours into making the FFOM site fabulous. Lori has been pregnant during this whole process and lives in New York City. She literally worked on the site right up until she was 41 weeks pregnant. I can't put a price on the value of what she has done for the Florida Midwifery community by gifting us her amazing skills to create this site, but the proof is there on the site for all to see. I shall be eternally grateful to her for putting up with my demands these last few months. Thank you Lori :-)

MANY MANY thanks to FFOMer Angela Bailey who has agreed to be our Assistant Webmaster and who really really come through in the final hours with her HTML and coding skills to help us get to the finish line. Her ongoing assistance has been invaluable.

For all others who helped - Sandi Blakenship, Sharon Dejoy, Heidi Dahlborg, Rebekah Finklea. Thanks for your kind words, your writing skills, your time. I/We couldn't have done it without you!

Join FFOM Today!

As we move forward with Florida Friends of Midwives and begin to craft a future for the group, one of the most important steps is to establish FFOM as an official legal not-for-profit entity and formally solicit membership. We need your help! Efforts great and small are needed to help this organization grow and to spread the word about midwifery care in Florida. FFOM welcomes as members all individuals, families, businesses, and organizations who want to support and
promote midwife-attended births in Florida. Membership fees support the ongoing work of FFOM in its educational, informational and future legislative efforts .

Become a “Supporter”. Joining Florida Friends of Midwives can cost as little as $1 for one year of membership.

Our membership categories were developed with working, growing families in mind. We want you to contribute as much as you are able. Whether you join at the $1 or $150 level, you are demonstrating your commitment to the future of midwifery in Florida. As a member of FFOM you become part of a growing movement of mothers and families committed to preserving and protecting midwifery in our State.

Not a member yet?

Follow these simple steps.

1. Join the FFOM Yahoogroup!

2. Download the membership form in the files section.

3. Mail in your membership form today.

Its time to organize to support normal birth in Florida!

At the 2007 Midwives Alliance of North America (MANA) Conference in Clearwater, Florida we decided to restablish the long silent Florida Friends of Midwives. We had no idea the response from consumers would be so great. We are so excited to note the amount of interest in FFOM and how our Yahoogroup has expanded in just three short months. WELCOME and thank you for your interest in this important cause.

This group has re-formed to discuss ways of organizing to cultivate a strong consumer voice in support of midwifery our State. It is our hope that FFOM will not only be a great place to support midwifery, but also for you all to support each other and educate other women about birth!

In Florida:

• Licensed Midwives can attend homebirths legally.
  
• 16 birth centers are owned and operated by Licensed and Certified Nurse Midwives (www.birthcenters.org).
  
• Two midwifery schools accredited by MEAC (www.www.meacschools.org)
  
• Medicaid and insurance coverage of licensed and nurse midwifery care is mandated by state law.
  
• Over 1500 babies are born into the arms of licesned midwives each year and that number is climbing.

What's the bottom line? Women have easy access to birth centers and homebirth midwifery care. In Georgia, one State away, there is one birth center and home birth (direct-entry) midwifery is illegal. Midwives can actually get arrested for attending home births there, and mothers looking for midwives have to find an "outlaw" midwife to attend them! In Alabama and North Carolina the story is much the same. Families who desire the care of midwives for homebirth, must seek that care without the networks and resources the women of Florida enjoy.

It is easy to forget just how good we have it here. The great conditions Florida's residents enjoy are due to political organizing done in the 80's and 90's by many - including crucial grassroots efforts by the Florida Friends of Midwives. Consumers and advocates of midwifery care lobbied our state government and succeeded in getting mother friendly laws passed in our State.

Political circumstances over the next few years are going to require a really strong family-mother/consumer voice in support of midwifery. Yes, homebirth midwifery is in danger of becoming illegal again in Florida if we do not organize to protect it.

Let's work hard as guardians of birth choices for ourselves, our sisters, our friends and perhaps most importantly - our daughters!

Heidi Dahlborg, LM
Midwife, Sarasota

Tamara Taitt
Region 3 Representative
Midwives Alliance of North America (MANA)

Shannon Mitchell
Information Services Director
International Cesarean Awareness Network (ICAN)

To join the FFOM Yahoo group visit:

http://health.groups.yahoo.com/group/FloridaFriendsofMidwives/