Following the trend toward inventing diseases and conditions that can be treated by new drugs on the market, the pharmaceutical world has presented women with a new condition that it can conveniently cure: too many periods. I discovered the condition on the back of the May/June issue of “Nurse Practitioner World News” sticking out of my mailbox.

I didn’t know we wanted this before now, but maybe we do? Seasonique, an oral contraceptive offering “fewer periods and, now, more savings” features in its new advertisement a healthy, happy, Patagonia-clad woman enjoying a fresh walk down the beach. She’s probably not having her period!

THIS IS AN INDUSTRY TRADE MAGAZINE ADVERTISEMENT. What’s so disturbing about this new birth control pill is not that it is available, but that the pharmaceutical industry has decided it can — and should — attempt to convince physicians, nurse-practitioners and midwives that it knows what women want. Big pharma understands fifth-wave feminist desires. It can provide us with the means to control and limit our monthly menses to seasonal inconveniences……until Annuelle™ comes on the market.

Personally I’ve used the pill (also called OCPS, or “oral contraceptives”) a few times in my teens and twenties. Back then OCPs seemed like the best fit for me. They weren’t messy, they weren’t scary in the way that IUDs or injections were, or freaky the way implants were. The pill appeared benign enough that one could practically forget they were taking a daily dose of synthetic hormones. Ultimately I became uneasy about the daily dose of hormones I was consuming. I began to recognize that some of the side-effects I was experiencing were the result of the additional hormone load. I remember feeling like some other entity had come in and taken up residence in my body.

While I am not a fan of increasing our exogenous hormone load, I am all for choices in contraception and I accept that the pill is the preferred method for many women. I wish, however, the trade-off for preventing unwanted pregnancies was not an increased risk of certain cancers. In my clinical life, I have had very few clients interested in hormonal birth control methods either because they are nursing mothers, they want to avoid exogenous hormones, or they hope to become pregnant soon.  Until now I’ve only been peripherally aware of the new option to have 4 periods per year instead of the regular 13 or so

Is this really what women want? Seasonal periods? The concept is alluringly pseduo-natural. Maybe this is your body…. in harmony with the four seasons?

There were times when toting along tampons or sponges or whatever was awkward, but I never found myself thinking “How can I get out of having these periods?” And I was one of those women who spent an entire day doubled over with severe cramping every month.(Perhaps my Catholic guilt played a role here). Are women so burdened by their monthly periods that a drug company felt compelled to save us all from our suffering by creating a new brand of birth control pill that “empowers” us to have fewer periods? Perhaps for women already committed to the pill, switching to one that eliminates most of their periods is not a significant stretch.

Suppose this product was created in response to consumer demand, and not the other way around?  What price will we pay for “seasonal” periods?  In an article about these kinds of OCPs, the Mayo Clinic counsels “you may notice bleeding or spotting between periods (breakthrough bleeding) when you extend the number of days between periods.” Spotting is casually presented as the only noteworthy side effect of these extended cycle OCPs.

In reality, we don’t have any long-term studies (more than a few years) on using OCPs this way. Decades of research on traditional OCPs however is clear about some major risks including heart disease, stroke, and blood clots. And what about cancer?  Research has shown that birth control pills slightly decreases the risk of ovarian and uterine cancer, while potentially increasing the risk of breast and liver cancer in some women. In 2006, the Mayo Clinic determined that women who used the pill before their first pregnancies had a 44% higher risk of breast cancer over women who had not used the pill.

The possibility of more breast cancer, even if the research flip-flops on the subject, is a big deal to me.  As an American woman I have a 1 in 8 chance of developing breast cancer in my lifetime — much higher odds than having ovarian or uterine cancer. Pills like Seasonique expose women to an additional 13 weeks of exogenous hormones over the regular combined OCPs.

While digging around for information on Seasonique I learned that the pharmaceutical industry in 2004 is estimated to have spent spend $57.5 BILLION dollars on advertising. The industry spent TWICE as much on advertising  as it spends researching and developing existing and new medications. I also learned that maker of Seasonique, Teva Pharmaceuticals, along with 12 other pharmaceutical companies, were sued by the state of Massachusetts in 2003 for Medicaid fraud.  These companies allegedly inflated the prices of their medications to their industry’s price reporting services, which in turn caused Medicaid to waste tens of millions of dollars in inflated reimbursements to recipients of the medications made by these companies. Your grandmother has to choose between food and medications while the folks at Teva are raking in obscene profits. All 13 companies in the Mass Medicaid fraud suit settled, returning roughly $23 million dollars back to the state’s Medicaid program.

Drug companies’ influence over physicians’ prescription pads is also obscene. In 2000 the drug companies spent over $20 BILLION dollars on private sales meetings between drug reps and physicians. The industry can afford to spend this amount of money on promotional meetings with physicians because it knows from experience that targeting susceptible physicians will ensure humongous profits. A former drug rep for Eli Lilly describes the nature of the drug rep/physician relationship:

It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.

—Shahram Ahari

What does this mean for the physician-patient relationship in discussing birth control options? I want to believe that providers would place their obligation to provide true informed choice about the risks and benefits of contraception options over cozy relationships with drug reps. But I recall my own experiences and  I fear for the women in their teens and twenties going in for their first yearly well-woman exams, and coming home with packs of pills, completely unaware of the money, advertising, and schmoozing efforts involved in getting those pill packs to the providers desk.

Some women might want these pills, and that’s OK. What do I want?

Instead of insurance fraud and a misrepresentation of these medications’ risks, I want transparency. I want the pharmaceutical industry to adopt a shred of decency and stop inventing and selling made-up conditions to women, and start spending more money on making its products safer than on advertising them to us. I want honest discussion about the possible risks. I want more choices and safer choices. What do you want?

I am stunned and saddened by Ms.Tuteur’s hate-filled critique. Rather than commenting directly on my blog, where I welcome sensible debate and where we could have engaged in a meaningful discussion, she deliberately exploited my statements out of context in what amounts to a personal assault on me and on the greater body of midwives in the US.

I use hemorrhage to illustrate the larger point that events in typical hospital births — and their outcomes — cannot automatically be extrapolated to out-of-hospital settings. Missing this point entirely, Ms.Tuteur cites maternal death from hemorrhage in impoverished nations where women are malnourished and do not have access to skilled prenatal or intrapartum care as evidence that I do not understand the gravity of hemorrhage, or the international causes of maternal death.

To be clear, I did not state nor imply that women do not hemorrhage at homebirths. Hemorrhage can occur in all settings and midwives are trained and equipped to manage them. However, for the record: published evidence from medical studies on homebirth in the US, Canada, UK, and Netherlands shows a 0% rate of maternal death from hemorrhage at home, and of the studies that compared hemorrhage rates between homebirth and hospital births, all showed a lower incidence of hemorrhage at home.

I welcome substantive discussion on my blog, that is how birth change is happening in this country — with open and honest discussion. Until now, I have not removed or censored any genuinely critical comments from readers. I will not, however, publish vindictive comments that reflect more of a personal attack than honest questioning or critical discourse. These kinds of comments do not serve me, my readers, or women seeking to learn more about their choices in childbirth.

I became a midwife before I birthed my own babies. After I became a mother, people often asked how my practice had changed. All midwives advocate for the needs of babies, but giving birth to my own baby gave me a visceral connection to the baby’s birth experience. I am more deeply tuned to the whole experience from their point of view, from their passage out of the pelvis (or abdomen) to their first moments touching, hearing and smelling their mother.

In thinking about how the majority of babies come into this world, I keep coming back to harmful cord clamping practices, one of the first interventions experienced by most babies born in the US. (Sometimes they are bulb-suctioned first). Cutting the umbilical cord within seconds of the birth, also known as premature or early cord clamping, is a routine practice of hospital births attended by physicians. It is another intervention that has become so second-nature to physicians, and has gone largely unchallenged in the delivery room.

One exception is Dr. Nicholas Fogelson, an outspoken advocate of “delayed,” or normal cord clamping within the medical community. While he draws a parallel between premature cord clamping and blood-letting in his latest video series, he is candid about his earlier experiences:

For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable.   Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations.  After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?…….

Some basic baby physiology, for context: During pregnancy, the baby’s blood circulates in a constant loop in and out of her body. It flows through the body, back into the cord to the placenta, then back through the cord into baby’s body. This pattern of circulation continues until shortly after the birth when the placenta separates from the inside of the uterus. By the time the placenta separates, virtually all the oxygen-rich blood in the placenta and cord (up to 40% of the baby’s total blood volume) has made its way back into the baby.

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

Why do physicians cord the cut so soon after birth? Most believe that babies if babies receive their full blood volume from the placenta they will have too many red blood cells (polycythemia) and become jaundice. They aim to prevent this by clamping and cutting the cord immediately after birth which stops the flow of blood from the placenta into the baby.

Also, it happens to be extremely convenient for the Swiss clockwork *ideals* of a hospital. Cutting the cord right away allows staff to get on with two other routine postpartum practices: active management of third stage (which includes early cord clamping, pitocin and pulling on the cord to extract the placenta) and routine baby assessment. While the doctor facilitates the birth of the placenta, nurses can move the unattached baby to the warmer to perform their standard newborn care and assessment. On the warmer, babies are typically suctioned, dried, swaddled, perhaps given oxygen, etc. Some mother-friendly hospitals have begun to perform newborn care on mom. (In homebirths, these things are almost always done on the mother’s abdomen, or just beside the mother, with the cord intact).

In premature cord clamping we have an intervention that has become almost universally embedded into hospital birth on account of convenience and a desire to avoid jaundice –  the only trade-off is a loss of up to 40% of baby’s blood!? Despite popular medical opinion, research favors delayed cord clamping for both preterm and term babies and has not found a significant association with either polycythemia requiring treatment or jaundice requiring treatment.

Two meta-analysis addressed the subject in the last five years — the JAMA and Cochrane reviews.  While the Cochrane review did report a small increase in jaundice requiring phototherapy among late cord-clamped babies (5% as opposed to 3% in the early clamping group), these results were based on one particular study that has been criticized by experts and physicians for a number of good reasons. It is an unpublished PhD paper written by one of the review authors, and since the study was not published or peer reviewed its design raises a number of questions: we don’t know whether the physicians referring to treatment were blinded, whether confounding factors were accounted for, or what threshold for treatment was used 12 years ago in Australia when the study was undertaken. The JAMA review found no increase in jaundice requiring phototherapy.

I’ve seen a good number of jaundice babies in my years attending homebirths, so for argument’s sake let’s say babies who have delayed cord clamping do develop more jaundice. Is really worth significantly reducing their blood volume in order to reduce their odds of becoming jaundice?  Jaundice is “physiologic,” meaning normal.  Many healthy babies will become jaundice regardless of when their cord was clamped. The vast majority of newborns with jaundice are normal and healthy and do not require medical intervention. Depriving infants their full blood volume is not a reasonable response to something as common as jaundice.

The placenta has been born and the parents are ready to clamp the umbilical cord. The baby has received her full blood volume.

Why should we leave the cords alone?
It would be senseless and highly dangerous and to remove a third of the baby’s blood from their body before they were born, but doing this immediately after birth has become the norm. Charles Darwin, the preeminent observer of morphology and behavior, recognized the danger in premature cord clamping in the 1800s:

Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.  As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child. (Zoonomia)

A little more physiology can help us understand why that blood is vital: Immediately after birth, babies transition from breathing amniotic fluid to breathing air. This change requires the heart to pump far more blood to the lungs than it had before. All the blood from the placenta and cord is needed in this process. The blood from the placenta also sends more oxygen around the body. This transition process can take longer and be more difficult if the cord is cut early, preventing the baby from receiving her or his full blood volume. In these cases babies often require supplemental oxygen — oxygen that would have been supplied by the umbilical cord. We know now too that keeping the cord intact during resuscitation actually helps babies who are having trouble transitioning and breathing. (Check out this new innovative mobile warmer unit from the UK that allows babies to be resuscitated with their cords intact).

Preterm babies also benefit greatly from delayed or physiologic cord clamping. The benefits of keeping their full blood volume extend beyond the newborn period into infancy as well. Babies have greater hemoglobin (iron) levels in the months after birth and benefit from the stem cells, antibodies and other life-sustaining components of their blood.

How do you know when the cord is ready to be cut? If the cord is still fat, taught, and spiral-ey, it’s not time to cut yet. If blood forcefully spurts out when it was cut, it was cut prematurely. It is almost always just as easy to wait until the placenta is born to cut the cord. In homebirths, midwives typically wait to clamp and cut the cord until it  has stopped pulsing or the placenta has been born. Waiting for the placenta also ensures that mothers and babies remain undisturbed in those precious and finite moments after birth.

I encourage women whose care providers insist on premature cord clamping to familiarize themselves with the subject and ask their physicians if they are aware of the body of research supporting delayed cord clamping. You are your baby’s best advocate!

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

Resources:

Leaving Well Alone: A Natural Approach to the Third Stage of labour  –  Sarah J Buckley, MD

Delayed Cord Clamping Should Be Standard Practice in Obstetrics  –  Nicholas Fogelson, MD

Cord clamping researcher Judith Mercer talks about her study of delayed cord clamping for preterm, very low birth weight babies

This exceptional short video features renown midwives and physicians discussing cord clamping practices and the effects on babies: We Can Be Much Kinder

I interviewed homebirth midwife Hilary Schlinger about the proposed name change and her vision for the future of midwifery in the US. Hilary is both a Certified Nurse-Midwife and a Certified Professional Midwife and has a long history in midwifery politics. She has served on the Midwives Alliance of North America board of directors and is the author of Circle of Midwives, a book about the history of the Midwives Alliance of North America and the resurgence of midwifery as a profession in the United States.

Sit tight, this is a long one but there is lots to chew on here.  For help with the acronyms, see the MANA glossary of terms here.


Erin: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?

Hilary: I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US. Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized. If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery? As a corollary, is it going to change the title of all its members to CM – Certified Midwife?

Here’s another way of looking at it: Let’s say that the pride of the membership of the ACNM was their position as APNs (Advance Practice Nurses), rather than their attachment to the title of midwife. And let’s say that a motion was put forward to change the name to “American College of Advanced Practice Nurses.” Members would still have to go to an ACME-accredited program and pass the AMCB exam – the educational path and certification exams of other types of Advanced Practice Nurses (FNPs, CNPs, and Nurse-Anesthetists) wouldn’t qualify. Would you expect the excluded nurse-practitioners to think the name change was a positive move? That it wouldn’t confuse the public, or legislators? That it wouldn’t have the potential to undermine the work by other nurse-practitioner groups on political and/or legislative levels?

Erin: But some ACNM members are saying that they need to be more inclusive of their CM members. Why is it important to understand the politics surrounding the creation of the CM credential?

Hilary: For those who joined the ranks of midwifery after the early 1990’s: The history of the CM credential is NOT one that the ACNM can be proud of. To understand why this is so, one must understand the context of the times.

In 1989, the first Carnegie Foundation Seminar on Midwifery Education was held, with joint representation from ACNM and MANA board members to discuss the expansion of direct entry midwifery education. One year later, Carnegie offered funds to establish an inter-organizational task force so discussions between MANA and ACNM could continue. A result of these meetings was the creation of the (original) “Midwifery Certification in the United States” document, jointly endorsed by the boards of both organizations in 1993. The document affirmed ACNM as the appropriate organization to oversee education, certification and advocacy for nurse-midwives, and of MANA to respectively do so for direct-entry midwives.

ACNM acted in direct violation of the agreement when, less than a year later, the idea of the CM credential was “sold” to the membership. Leading the charge for creation of the CM at the ACNM convention was the NY ACNM chapter. In essence, New York was being used as the “testing ground” for an ACNM brand of direct-entry. While other states were concentrating on defining nurse-midwives as advanced practice nurses, the legislative push in NY was to separate midwifery out from nursing. When I say ‘midwifery’ here, I mean ‘nurse-midwifery,’ as their intention was never to include the voice of the existing (but unlicensed) DEMs. The New York CNMs saw themselves being held back by nursing issues, and felt that the creation of a Board of Midwifery was their best route to controlling the parameters of their own practice. Add to this the desire of some influential CNMs to design a European-style direct entry for the US – and NY became the perfect place to test this concept.

So, when the New York midwifery law passed, the CNMs from that state needed the ACNM to move quickly in acknowledging its own route to midwifery separate from nursing. Again, they saw this new law as a triumph, as the opportunity to design midwifery according to their own visions, and this included the opportunity to create direct-entry education. And the last thing they wanted was to muddy their dreams with concerns of those outside their ranks. They didn’t want to talk about place of birth, or about CPM-style education – they wanted to create a brand of direct entry that they perceived would be acceptable to the American public – Master’s Degree educated, prepared for hospital practice, just not entwined with nursing.

In “selling” the idea of the CM, the membership was told that creating the CM was “good for” the existing DEMs because it would create a legitimate route for their practice. This couldn’t have been further from the truth; there was no intention of creating a mechanism for us to achieve certification – it was, and has continued to be, a route in direct competition for legitimization with the CPM.

Although the move to create the CM was a politically motivated effort, with the subtext of undermining MANA, NARM and MEAC by creating a direct-entry pathway that could be touted as more legitimate, it is not one that has been successful. We need only look at how the CM has floundered while the credibility and acceptance of the CPM has grown to observe that this effort has failed. However, if the name change goes through, I am anticipating a re-doubling of ACNM’s legislative efforts to promote the CM as a more legitimate direct entry midwife, and to block inclusion of the CPM.

It is naïve to think of this current proposal as altruistic, or to think that actions of the ACNM won’t affect all midwives. It is always telling to know your own history.


Erin: Voices within ACNM are promoting the name change as a step toward unity within the profession. What do you think?

Hilary: The ACNM is an organization whose charge is to represent its membership, but when that organization has been built on excluding those whose voices don’t fit with its philosophy, how can I trust that the future will be different – that the “new and improved” American College of Midwives is interested in building bridges? With the creation of the CM, they were so willing to burn the bridge they had built with MANA the previous year, because of self-interest. Now, I would like to hope that times have radically changed, that any political currency the organization has gained over the years will be spent on the promotion of midwifery as a whole…but I would not go to the bank with this hope.


Erin: Many would argue that a similar oppressive/hierarchical dynamic is occurring between NARM/CPMs and DEMs who choose to remain uncertified and/or unlicensed.

Hilary: This is not a new dynamic. There has long been a rift between those midwives who perceive certification as limiting to midwifery practice and those who seek out certification, who want to find a way to be included as legitimate providers in the healthcare system.

NARM was born out of a desire for midwives to create their own standards regarding the parameters of midwifery scope of practice and education, rather than waiting for these to be imposed on midwives by the individual states. I happen to believe that staying out of “the system” keeps midwifery care limited to those elite (usually middle class white women) who can afford to pay out-of-pocket for care, as well as making individual midwives vulnerable to charges, whether real or spurious, from any of those in power who feel threatened.

In order for midwifery care to be readily available and for home birth to move beyond the one percent, I believe we need to find a mechanism that allows for our inclusion in the greater health care system. And of course the goal is for this to occur without destroying those qualities which make midwifery unique. I think the NARM/CPM approach holds more potential for achieving both these goals simultaneously than the ACNM one, which I perceive as being willing to dilute midwifery to a greater and greater degree as long as nurse-midwives gain a foothold in “the system.” Theirs is not the model I want to emulate. However, if we step carefully with certification and licensure, being very cognizant not to compromise away our principles in the process, then I think many of those midwives who currently choose to remain uncertified or unlicensed may look differently at the process.


Erin: You started out as a DEM turned CPM, but eventually became a CNM despite your criticisms of ACNMs political tactics and being exiled from New York. Why?

Hilary: I have alluded to my personal involvement in the events that occurred in New York.

When the law changed in 1993, I and twelve other DEMs applied for midwifery licensure. During the prior legislative fight to establish midwifery as an independent profession in the state, we had been assured by the CNMs that we would have at least one seat on the New York board, which was never their intent, and did not happen. Furthermore, we had been led to believe that our educations would be individually considered under a provision in the New York law which allowed licensure for those who could prove educational “equivalency” to CNMs. Instead, the information we provided in our applications was forwarded to the punitive arm of the department, and eight of us received cease-and-desist orders, with felony charges if we failed to comply.

I chose two things: to relocate to a state where I could legally practice, and to continue pressing the New York Department of Education to declare my education as “equivalent.” This fight took over seven years, but finally, after enormous effort, in 2001 my education was deemed “comparative.” I was given clearance to take the ACNM boards, which I did in November of that year, and thus became a CNM without ever attending a CNM program. By doing so I opened a door to licensure that approximately 15 other DEMs have since stepped through. It was a point of pride for me that I not attend an ACNM-created CM program, but instead have the state declare my existing education as equivalent.

Eight years later I chose to attend the only ACNM-accredited school where I could obtain a Masters of Midwifery rather than a Masters in Nursing, not because I needed this degree to practice, but to expand my ability to be involved in the future of midwifery education.


Erin: Is a perceived lack of education the primary reason ACNM fails to support NARM and the CPM credential?

Hilary: I’d like to tie that question to our history. During our discussion, I have been taken back, again and again, to the original convictions that kept me from becoming a CNM during the 1980′s and 90′s. During the time that I was working illegally in NY, I had more education than many of the CNM’s in my community (a bachelor’s from an Ivy League college plus midwifery training at The Maternity Center in El Paso plus licensure as a midwife in New Mexico, at a time when most CNMs were ADN’s who had gone to Newark for 9 months to obtain their midwifery certification), as did the women I worked with (3 of whom were British-trained direct entry midwives). I also had more birth experience than many of the CNM’s around me, and I certainly didn’t see the need to repeat my midwifery education. Yet my education wasn’t acknowledged as such by the CNMs in the state. Was this because the education was inferior, or because it incorporated a philosophy at odds with the CNM educational model?

When the New York legislative push came to the forefront, I spoke publicly about how the New York DEMs needed to be included in the process. And those of us involved weren’t just any DEMs – of the three primary DEMs involved in the legislative effort, two were founding members of NARM, and I was then the North Atlantic representative to the MANA board. In our naïvety, we believed that if we participated in the legislative effort, if we demonstrated the validity of our education and practice, then we would find a place at the table. But this didn’t happen – instead, our voices were forced out, and all three of us ultimately ended up leaving the state. In essence, it became clear that our having more experience with direct-entry (and, for some of us, higher educational degrees) than the CNMs in the state didn’t matter; the point was that our goals didn’t line up with theirs.

So now, when the ACNM has twice raised the educational bar, and can thus wave the flag of “education” as the primary difference between CPMs and CNMs I have to sit back and ponder, “Is this really the issue underlying it all?” And my answer is a resounding NO. If the ‘sticking point’ back then had been education, surely those of us with national experience in direct-entry education would have been welcomed at the table during the planning of CM programs, not barred from participation.

What it boils down to for me is that the roots (and subsequent actions) of the ACNM are in the gaining of power and legitimacy by being presentable to the powers-that-be. Even though the ACNM was born from out-of-hospital midwifery (be it in Santa Fe, Hyden or NYC), the emphasis from the start has been on incorporating midwifery into the existing medical and educational systems. And if this meant that those midwives had to wear a nurse’s cap, so be it. And if it later meant that they had to obtain a higher degree (regardless of their own research showing that ADN/certificate midwives had superior performance on the job), then so be it. And if it meant that they had to present a more medicalized version of midwifery in order to gain entrance to hospitals, then so be it.

Thus the question isn’t about “educated” versus not, but about the acceptance of midwifery knowledge that is both applicable to and acquired outside of, versus inside of, institutions.

This comes back to your question of how CPMs are viewed by the CNM community. One of the largest misperceptions about CPMs is that they have no didactic education, because for many it has occurred outside of the walls of standardized institutions. CPMs are all educated; however, a substantial percentage have not opted for “traditional” institutionalized education, often for the same philosophical/political reasons that lead them to avoid birthwork in medical institutions.

For those who don’t know, the NARM credential was created in conjunction with the National Assessment Institute to be in line with accepted psychometric standards. To quote Ida Darragh of NARM, “NARM does have a required curriculum – over 800 topics – which must be mastered both in theory and in practice.  There is no requirement that it happen in a classroom, but it must happen and must be verified by a qualified preceptor through over 50 pages of documentation.  All candidates then must pass the exam. It is NARM’s job to evaluate the educational pathway. There IS education, and it IS evaluated.”

We are seeing a veritable revolution in “non-traditional” education within many fields. Programs such as Empire College within the State University of NY system grants credit for demonstrated life experience, and Harvard admits homeschoolers. Both ACNM and NARM recognize didactic education online (ACME via Philadelphia University, Frontier, and SUNY Downstate; MEAC via National College of Midwifery, Midwives College of Utah, to name a few). So if both CNMs and CPMs now mutually acknowledge that nursing is not a prerequisite to midwifery, and as a society we are increasingly acknowledging multiple routes of education, then why are CNMs reluctant to acknowledge NARM certification as valid?Is the issue really about education, or is it about the underlying philosophy?

To turn the scrutiny the other way, we need to look at CNM education, as well. Most CNM education is lacking in continuity of care, in large-volume birth experience, in non-technological birth, in hands-on labor care, in newborn care, and the majority of ACME-accredited programs are educating CNMs only for employment in hospital settings, not for out-of-hospital (or even for true full-scope midwifery) practice. As a dually-educated midwife, I see the practice and the educational scope of each branch as overlapping circles – neither has it all, but merged together they would encompass the full scope of midwifery.

Erin: You’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing women? Wouldn’t it mean less choice for them?

Hilary: It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

I believe that there is great potential for merging the two branches of midwifery via education, specifically via educational opportunities that have evolved due to the internet, as well as by weaving innovative midwifery programs into state colleges. Imagine a system where each midwife is educated (and permitted) to practice in all settings, incorporating the best of both NARM and ACME educational elements. Imagine a system where women who want to be midwives do not, on the one hand, have to spend years studying nursing when their true goal is midwifery; or, on the other, spend years studying midwifery, yet have no college credits to show for it. Imagine that midwifery education is available in every state college system, thus increasing the diversity of the midwifery population while decreasing the educational costs. There are waiting lists for state nursing programs; but I would bet that a fair number of those standing in line would jump at the chance to become midwives instead (and I’d bet that, for some, this was already in their plans). Imagine that we build birth centers in rural communities which serve the dual purpose of providing needed care while providing training sites for midwifery students.

And, if you can, imagine that we channel all the energy we have been wasting on fighting each other, and instead make a concerted effort to grow the profession. Imagine that the word “midwife” is known to every pregnant woman, and we read “more women demand midwives” in our local papers. We could stop celebrating when the number of midwifery-attended births in a particular state have reached the double digits, and instead look forward to them becoming the majority.

I am privileged to work in the state with the highest percentage of midwife-attended births in the US. Not surprisingly, we also have the lowest percentage of cesareans in the nation. I have full prescriptive privileges, the ability to provide primary care, am an independent provider, can write my own practice guidelines, and am reimbursed by all health insurance plans, including Medicare, Medicaid and private insurance. I am not saying that everything is ideal here; for example, hospitals are not required to grant admitting privileges to midwives, there is still a rift between the majority of CNMs and CPMs, and I only know of one midwife in the state who attends both home and hospital births. Still, I have gotten a glimpse of the vast potential for midwifery by working in New Mexico over the past 15 years. I believe that expanding the scope of practice for CPMs to include more well-woman and primary care, while simultaneously expanding the education and practice of CNMs to include more of the “midwifery model” qualities that CPMs hold dear, would serve to broaden choices for all women. It is only our misperceptions and petty squabbles that keep us from achieving unity. We will never know what opportunities for midwifery expansion are available as long as we continue our in-fighting. The current system limits choices; joined together we would have a much stronger voice, and the potential to reach all American women.

Hilary Schlinger, CNM, CPM, MS, RN, is a Certified Nurse-Midwife (ACNM), a Registered Nurse and a Certified Professional Midwife (NARM). She holds midwifery and nursing licenses in both New York and New Mexico. She first became a Licensed Midwife in NM in 1982. Hilary has attended approximately 1000 births, with a focus on home birth practice, and has provided well woman care for hundreds of women. Hilary holds a Bachelor of Science degree from Cornell University, an Associate of Science in Nursing from Regents College, an Associate in Midwifery from the National College of Midwifery, and a Masters in Midwifery from Philadelphia University. She held a seat on the Board of Directors of the Midwives Alliance of North America for four years. Hilary is the author of the book Circle of Midwives, editor of four midwifery texts, and has been a guest lecturer and workshop presenter in settings from medical schools to midwifery conferences. She has served as preceptor for numerous midwifery students, and is currently a faculty preceptor for the National College of Midwifery as well as adjunct professor for the Department of Continuing and Professional Education at Philadelphia University, where she teaches the on-line course “Homebirth Practice Essentials.” She lives and works in Albuquerque.

When I hear statements like this I cringe on the inside.  Being a midwife, I hear it a lot.  Women love to talk about their birth stories, naturally. In the park, at mom’s groups, among new friends, anywhere women gather there are stories of births and babies being told. When I hear a story being told from the “I would have died at home” perspective, I nod in empathy and say mmm hmm.

A typical hospital birth hook-up: pitocin to speed up labor, epidural medication, and an IV bag. Pitocin use in labor makes women more likely to hemorrhage after birth.

It’s a bit of a double bind (midwives and doulas — you know what I am talking about). In these moments, I strive to listen with deep gratitude, kindness and love. Every woman’s story is inherently valid and it is her story to tell, her journey. On the other hand, my inner advocate of truth and justice wants to illuminate the myths and realities of the hospital birth industry; very often the emergencies are caused by unnecessary interventions.  The best I can do is to honor the mother’s feelings and experiences while side-stepping all the nuts and bolts of the “I/we would have died” argument. That can get messy.

But since it’s coming up in the again in the media and a larger audience of women is hearing such emotionally charged statements about homebirth, it’s time to get messy. Why do women in the US die while giving birth? No one knows for certain because our reporting methods for maternal mortality are so abysmal. We think, based on fractured US statistics and older studies, that the primary causes of death to women during birth or shortly after are thromboembolism, preeclampsia/eclampsia, hemorrhage, infection, and anesthesia deaths.

Lets look at hemorrhage because it is the most likely of these unlikely complications to occur in low-risk women birthing at home.

Here are a few reasons why. Homebirth and hospital birth are supported by two divergent models of care. The homebirth model subscribes to the philosophy of don’t fix what isn’t broken: natural processes generally work best when they are not interfered with. The medical model subscribes to the (more profitable) philosophy of action: pregnancy and birth are conditions that require fixing.  All actions and interventions have consequences. Many of the interventions in a typical hospital birth cause complications, like hemorrhage.  These interventions do not happen at home.

New research demonstrates that women whose labors are altered by prolonged exposure to pitocin are more likely to hemorrhage after their birth. This is because oxytocin, our body’s own version of pitocin, helps the uterus to contract after birth and minimize blood loss. Pitocin binds to oxytocin receptor sites, and over time the body becomes desenstitized to it, preventing the uterus from contracting normally and leading to hemorrhage.  Regrettably, we’ve gotten to a point now where most births in the US are started artificially with the help of pitocin (induction) or hurried along by it (augmentation). Homebirth midwives do not use pitocin to start or speed up labor.

Immediate postpartum interventions can also lead to hemorrhage. The period just after birth is a unique and potent time biologically for the mother and baby. A natural flood of hormones connects mother and baby physically and emotionally, and helps the mother safely birth her placenta. The mother’s hormone levels will never be as high as this hour after birth; and when this flow is is disrupted the mother is more likely to bleed excessively.

Interventions during this immediate postpartum time are routine in a hospital setting: failing to give the baby to the mother immediately, assessing the baby away from the mother, pulling on the umbilical cord, changing the mother’s position to suit the care provider, diverting the mother’s attention away from the baby, clamping and cutting the umbilical cord without any good reason to do so, etc.

Midwives honor the biological importance of the hormonal bubble after birth and do not intervene unless the mother or baby needs help.

In a typical homebirth, mother and baby are undisturbed after birth. The midwife does not unnecessarily poke, prod, clamp, or otherwise interfere with the mother and baby unit.

When you hear someone say “I would have died if I had a homebirth” or “my baby would have died” please remember that these are very emotionally charged declarations. Yes, tragic outcomes do occur in any setting despite the best possible care. However, in many hospital births, it is unnecessary interventions that have caused the complications that women and babies suffer from. (The CDC has estimated that half of maternal deaths are preventable).

You cannot simply cut and paste all the circumstances surrounding a given hospital birth, superimpose them on a homebirth setting, and predict the same outcome — or vice versa. The models of care are too divergent. Women can die from birth complications in any setting, and our hospital death rate from birth-related causes is indefensibly high. We know that low-risk women are as safe, if not safer, birthing at home.

The United States ranks 41st in maternal mortality among nations. That means in 40 other countries, women are less likely to die from pregnancy and birth related causes. The CDC also states that half of the reported deaths were preventable and that death rates are underreported by almost a third. On April 9th the Healthy Mothers Healthy Birth Summit will convene in Washington D.C. to examine the clinical and political issues surrounding maternal death in the United States.

EC'ing my seven month old after the long winter inside. Warmer climates are great for EC'ing.

Since I’m neck-deep in the mother-baby cocoon these days I thought I’d share my EC’ing experiences in hopes of helping any curious mamas or papas to give it a try! The process of being attuned to your child’s elimination rhythms is something mothers do everywhere although it is less common in western cultures where disposable diapers are so popular. Infant toilet learning goes by many names, the least fortunate of which, in my opinion, is “Elimination Communication.” I can’t really say it with a straight face, so I’ll refer to it here as ‘EC’ing.’

I started EC’ing my first born about three weeks after his birth. One day I held him over the toilet, and he started to pee.  Boys can be hilarious to EC if you have a sense of humor. Their pee can shoot unpredictably in just about any direction. This makes night-time EC’ing trickier in the winter time, but for us it was still worth the added effort.  My son did not poop in a diaper after he was three months old, and by eighteen months he was wearing underwear full-time and independently taking himself to the toilet.

The books tell you people do it for the “communication” aspect; that babies indicate wen they need to go, parents respond, and there is an ongoing ‘dialogue’ around the baby’s cues.  As a tiny baby, my son would get show a little fuss before peeing, but as he grew out of the newborn phase, he never really “cued” when he had to pee, at least not in any way I recognized. With him it was all about timing. If it had been 15 minutes since his last pee, I’d take him to go. I’d take him to go after waking up from naps, and more frequently after nursing. Easy.

Baby Morgan and mama Jenna

I remember one day in particular when he was maybe five or six moths old. An hour had gone by and I realized hadn’t taken him to pee and he hadn’t peed on his own. It was a milestone! All the work of the first few months paid off. From then on EC’ing required far less of my attention. It was around this time that he began staying dry at night, which made the initial work doubly worth it.

My daughter is now six months, and our EC’ing experience has felt even more second-nature. We started at birth, and her patterns are more predictable than my son’s. Her only poopy diapers have occurred on a boat and on an airplane. Both times I knew she had to go but I could not easily get us to a toilet. That’s not to say I’ve caught all her pees! Puddles on the tile floor are still a regular occurrence when I am not entirely attuned to her, but they all part of the process and i don’t sweat the “misses.” I much prefer to quickly wipe up a pee puddle than undress, change a diaper, re-dress, etc.

I am home mothering my kids so I am physically around to do this. If you have work besides raising your kids, EC’ing poses additional challenges, but it is not an all-or-none process. You can EC part-time, or whenever it works for you. It is a lot of work at first, but the payoff comes quickly and beautifully: less diaper changing, less money spent on diapers, less laundry, no drama (or virtually none) over “potty training” when they are older.

While not meant to be a how-to list, here are a few bits I’ve learned from my experiences thus far:

Let them go naked when you can. Going diaper-free at home is the quickest way to get in tune with your child’s elimination patterns. It is exponentially easier if you simply don’t put a diaper on them.  Without even being aware of it, you will begin to make associations between their behavior, i.e., their “cues” if they make any, and when they have to go. When babies are wearing a diaper you don’t have to pay the same amount of attention; you subconscious awareness of their patterns is not as dialed in because a diaper is there to catch the pee or poop. Keep them naked. This is my #1 piece of advice.

Don’t be afraid to be peed on! Seriously, it’s only pee. (And it’s sterile). If you are using cloth diapers you would have to wash a wet diaper, and washing wet pants is not any different. If you are using disposables, you’ve saved yourself (and the landfill) a diaper. Most babies will give some warning before they poop, particularly if they do not have any food sensitivities contributing to explosive bowel movements. (Did you see in the movie “Babies” the Namibian mother effortlessly scrape her baby’s poop off her knee?)

Keep prefolds and pee buckets handy. It’s a lot easier to “catch” a pee if you have something right there to catch it in. Our house is small so I just get up and walk into the bathroom. My son was an explosive pooper though and if I didn’t have a bucket handy I would have never made it to the bathroom.

Food sensitivities can make them pee more frequently and affect their bowel movements. Early detection of food sensitivities and allergies is benefit of EC’ing. You’ll notice if your baby begins to urinate much more frequently than normal, or if her poops are strained or otherwise abnormal.

This is a typical EC position for the baby. Youre basically supporting a squat, and the position becomes a "cue" for them to go. My son was a hefty two months old here.

Babies have preferences too. You know how sometimes you can be so engrossed in a project, or your thoughts, that you will endure the urge to pee until you really have to go? Or, maybe you have multiple bathrooms in your house but for some reason you prefer one over the others? Babies too have little quirks around eliminating that can change periodically. Both my babies got to a point when they needed something to focus on while they were on the toilet. They had to have a little something to hold or munch on before they could relax and pee. My daughter also prefers the toilet, while my son preferred the sink. My daughter will refuse  to be held “in position” if she has to burp. If she arches her back and tries to wiggle out of it I know she has a burp stuck in there and there’s no way she’ll pee until she gets it out.

It will teach them about their digestion. When toddlers poop on a toilet they have the opportunity to observe it and learn about their digestive health. Because my son has always pooped in the toilet, he is accustomed to looking at his bowel movements before he flushes them. He understands the connection between what he eats and what his stool look like.

The clear mini-potty was useful in areas where there was no toilet close by, and it allows you to see when theyre finished.

Girls are easier to EC than boys (generally). I have observed this in others children and have found it to be true for my own kids. Part of this is anatomical — boy pees are harder to catch as babies. With girls, everything more or less just dribbles downward. Diaper-free overnights are also easier with girls because you don’t have to worry about the sheets and blankets above getting wet in addition to the sheets underneath. If you have a baby boy, know that it only gets easier should you have a girl in the future.

People will be suspicious. Or think you are weird. They might not say it to you, but many will think it. I was talking to my grandmother recently about EC’ing my daughter and she said “Remember when we all [the entire extended family] laughed and thought it was ridiculous when you took him to the toilet as a baby, well I can see now that it was a sensible thing to do… ” referring to my son being toilet independent at age two.

TRUST YOUR INTUITION. I can’t tell you how many times I’ve known my daughter needed to pee, but I turned my attention elsewhere, or second-guessed myself, and got peed on thirty seconds later.  In a way EC’ing is an exercise in developing your instincts as well as your baby’s. If you have the sense that they have to go, they probably do.

In some high-risk situations these things may truly be helpful for moms and babies, or for mothers who choose epidural medications. But most healthy women do not need to be hooked up to anything in order to safely birth a baby.  Imagine how different hospital birth would be if most women could move around at will without any sensors or straps attached to them. Imagine women moving instinctively in ways that made their bodies feel more engaged, relaxed, and productive.

How might the freedom to be mobile affect their sense of privacy and autonomy? How might nurses and doctors entering the room approach a woman who was walking around, rather than confined to the bed? When you are up and about and getting into your labor’s rhythm you are a lot less likely to passively accept the battery of routine procedures, vaginal checks and so on. I believe — I know — that women would have more self-confidence and a stronger connection to their primal birthing instincts if they could move how and where they pleased without being attached to fetal monitors — an incessant reminder that their bodies or babies could fail at any moment.

Electronic fetal monitoring (EFM) can help us to observe what the heart is doing, how well oxygenated the baby is, and whether the baby appears to be struggling or happily trucking along. EFM became routine in the 80′s under the assumption that it was going to save babies. It was believed that continuous monitoring would pick up the small number of babies who show signs of hypoxia or distress and save them by cesarean section. We now know that a baby’s heart rate in labor is not great indicator of how well the baby is going to do after s/he is born. Regrettably, the technology has been applied in such an extreme manner — virtually all women in the US are attached to a fetal monitor during most or all of their labor — without consideration of whether there could be too much of a good thing.

Studies on EFM were undertaken only after it became a routine part of hospital birth. We now have decades of evidence showing that continuous EFM has no effect on neonatal mortality or morbidity; it does not help babies be born any healthier.  It does however increase the risk of cesarean birth by about three times. Physicians know this, and many will even admit it. Both the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care recommend against routine EFM for low-risk women, and cannot even recommend it for high-risk women in labor. Why then are healthy, low-risk, un-medicated women still being confined to fetal monitors when we know they don’t make birth any safer?

1) Electronic fetal monitoring produces a written record of the baby’s heart rate and it is believed that this record will help protect physicians against claims of malpractice or negligence should a patient decide to sue.  As one labor and delivery nurse shared on the My OB Said What?!? site:

“We always do continuous fetal monitoring, not because we think it helps, but just for legal reasons.” — A labor & delivery nurse

2) It is easier for nurses to manage multiple patients when they are being monitored electronically. Nurses already perform the majority of care given to women in labor and they have heaps of charting to keep up with on top of patient care. A well-known physician and midwifery advocate confided to me that, as with many aspects of maternity care, EFM boils down to dollars and cents. Keeping women strapped in and hooked up affords hospitals a higher nurse-to-patient ratio.

There is another option: periodic monitoring with a hand-held doppler (or fetoscope if you are hoping to avoid ultrasound). This kind of monitoring is called “intermittent auscultation.”  It is what midwives do at homebirths. ACOG even supports it, but it requires one-on-one nursing care, something hospital labor and delivery units do not provide. It also requires the unit keep a doppler readily available. I have attended countless hospital births where women are told they could be monitored with a doppler but there is no doppler to be found. ( I wanted to include a photo here of a hand-held doppler being used in the hospital. After about forty-five minutes of searching I gave up.)

Some women question their care providers prenatally about how long they will be hooked up to the monitor. They are frequently told they will only have to be on the monitor periodically each hour, but countless mothers will attest — it is a slippery slope. When you add in pitocin and pain medication, or a “concern” about the baby’s well-being, periodic monitoring turns into continuous monitoring (cEFM) rather quickly. When one intervention leads to numerous others we call it the cascade of intervention. EFM is a significant component of this cascade.

This is an area however where pregnant women can affect change. You can demand the freedom to be mobile in labor. You can demand to labor without electrodes and sensors on your belly. The science is on your side. Midwives are on your side. ACOG is even on your side (in writing). So yes, you CAN say no to the monitor, but you better bring your own doppler  …and your own nurse.