Pregnancy Update: 36 weeks!

I really have been in denial about this baby coming! Two nights ago, I had some serious feeling pre-birth pressure waves (Hypnobabies lingo for false labor), and I think that made me finally start to accept that this is really going to happen!

I have had two midwife appointments since I posted my last pregnancy update. At my 32 week appointment, I learned that the results of my glucose screen were excellent. I also learned that there had been a mistake with the tube the blood was drawn in for the CBC I had drawn at the same time. I decided to re-draw it because I really wanted to know what my iron level was. The midwife and I discussed the supplements I was taking, and she told me the vitamin D I was taking (2,000 IU) was probably not high enough. A recent study found that routine supplementation with 4,000 IU in pregnant women (ten times the current recommended daily intake) resulted in no harm and better outcomes. Considering that my level was very low in my prenatal blood work (and that was in the spring time), I need to be taking a much higher dose, so I have upped it to 10,000 IU a day.

A couple days later, my midwife let me know the results of my CBC--my iron was low. Not dangerously anemic low, but low enough for me to feel tired. I started taking Floradix, and feel so much better. I realized that the amount of sleep I was needing to function (about 9-10 hours in a 24 hour period) was not normal, and I have so much more energy now. I am keeping my house clean while busy with preschool and Hypnobabies and feel like I'm staying on top of things pretty well! I took it in my last pregnancy when my iron came back a little low at the same time and I thought it increased my energy level then, too. Why didn't I start taking Floradix earlier? Probably partly because Floradix is really expensive...

My 35 week appointment was a nice, long one. We talked about everything we need to do to set up for the birth. I asked about placenta encapsulation, and how I am interested in it but I'm not sure because there doesn't seem to be much definitive evidence out there. She said that everything she had seen about it is very positive. I have a friend who does encapsulation, so I might just have her do mine. The midwife said that they will make sure to take care of the placenta if I decide I want to have it encapsulated.

Somehow we got on the subject of cord clamping and I said that both of my prior two babies had their cords clamped earlier than I wanted. She said that they prefer to wait a long time, because even after all the blood has gone to the baby, there are stem cells that transfer from the placenta to the baby. I said that with my prior babies, they were taken away to be given oxygen, deep suctioning, etc. The midwife explained that it is possible to do those things in the mother's arms. She explained that at a recent neonatal resuscitation class she attended, she demonstrated, using the neonatal resuscitation doll, that the way that people instinctively hold newborns actually keeps their airways open.

The fee for my midwives is paid and the birth kit is ordered! My midwife will be giving me the birth pool next week, and I also ordered a liner to go in it along with my birth kit. I have a student doula who will be coming to the birth to help out with whatever we need--filming the birth, helping with the kids (who I plan to have present, as long as they want to be there and are not bothering me), helping with Hypnobabies tools, etc. I really want to capture this birth on film, which is something I didn't do with my others. I am really happy to give this opportunity to this student doula--I know I appreciate those who agreed to be my first few doula births! She is working on a nursing degree and hopes to eventually do a Masters in Midwifery at Bastyr, so I think seeing my birth will be great for her!

Comparison of Midwifery Education in Different Developed Countries

A couple of months ago, Amber at Midwife{ology} wrote a post, Educational Standards of American Midwives: A Comparison, which compared the direct-entry midwifery education program she left to the nurse-midwifery education program she is currently pursing. She points out what she sees as a huge discrepancy in the training of these two different types of midwives, and concludes that CPM training is inadequate to prepare a midwife to be a competent birth attendant. Stephanie at Nurturing Hearts Birth Services (who I highly respect as a midwife and appreciate for the wonderful midwife's perspective on Hypnobabies she wrote) responded in her post CNM vs CPM by saying that she feels that the training of CNMs and CPMs are different because they have a different scope of practice: CPMs attend only out-of-hosptial births with low risk women who are not being medically induced or receiving drugs, while CNMs are trained to work with medical interventions in a hospital environment and do pretty much everything an OB can do except vacuum/forceps assisted births and cesareans. Training for CPMs is different because what they need to know is different. Good points on all sides.

I think that maybe comparing different midwife certifications in the U.S. is the wrong comparison, and we should be comparing American midwife training to midwife training in the rest of the developed world.

The United States: In the U.S., the types of midwives practicing fall into three basic categories:

• Certified Nurse Midwives (CNMs): Those seeking this path must train as a Registered Nurse first and obtain a Bachelors of Science in Nursing (BSN) or the equivalent (usually through a "bridge" program), and then complete a midwifery program. CNM clinical training focuses mostly on hospital birth, and most CNMs attend hospital births, though some work in birth centers or have homebirth practices.
• Credentialed Non-nurse Midwives: This path to midwifery is for those who do not have and are not seeking a nursing degree. These include those with the Certified Professional Midwife (CPM) credential obtained through the North American Registry of Midwives (NARM), the Certified Midwife (CM, which is only recognized in 3 states) credential from the American College of Nurse Midwives (ACNM), and various credentials bestowed by state licensing, such as Licensed Midwives (LM), Licensed Direct-Entry Midwives (LDM), or Registered Direct Entry Midwives. Different states have different requirements for their licenses. A midwife can obtain both her state license and a CPM (in some states a CPM is required to get a license, some states have requirements above what the CPM credential gives). There are multiple training paths for a CPM, including MEAC-accredited midwifery schools and apprenticeship options. All must pass the NARM exam. For more information, see the NARM website. These midwives practice almost exclusively out of the hospital and very rarely get training in hospital birth.
• "Traditional" or Non-credentialed midwives: Licensure for non-nurse midwives is available in about half of the U.S. states. In the others, there are midwives who practice without licenses. Some do go through the training process with NARM, but they are still not legally allowed to practice. Some midwives in states that offer licenses choose to remain unlicensed, and do so illegally, except in Oregon and Utah, where it is currently legal to practice midwifery without a license. Training for these individuals varies widely.

United Kingdom: In the UK, there is one type of midwife training, done through a university. Training in nursing is not required, but those who have it have a head start in the program, so there must be overlap between basic nursing and early midwifery training. Midwives in the UK are qualified to attend births in all settings, home, hospital, and birth center. From the Nursing and Midwifery Counsel:

Education and training

In the UK midwifery education and training programmes are only run at NMC-approved educational institutions. Courses usually take a minimum of three years, unless you are already registered with the NMC as a level 1 (adult) nurse, in which case the training can be reduced to 18 months.

Midwifery training takes place at a university, with at least half of the programme based in clinical practice with direct contact with women, their babies and families. This can include the home, community and hospitals, and in other maternity services such as midwife-led units and birth centres.

Canada: Midwifery training in Canada is done through university education that prepares midwives to be able to attend both home and hospital births. From the Canadian Midwifery Registers Consortium

Midwifery education in Canada is offered at a university baccalaureate level. Education programs are “direct entry” (i.e. there is no nursing or other credential required for entry).

One example: The University of British Columbia Midwifery Education Program

The Midwifery Education Program at UBC is a four-year, direct entry, full time undergraduate program leading to a Bachelor of Midwifery degree. The curriculum combines broad-based knowledge and understanding in the humanities and the social and bio-medical sciences. . . .The first two years of study are located on the UBC campus and in the area of the Lower Mainland. The final two years, including the summer between years 3 and 4, consist of clinical courses. . . .Students are prepared for practice in both high tech and low resource settings (home, hospital, rural, international).

Australia: From the Australian College of Midwives - New South Wales

To become a midwife you need to complete either a Bachelor of Midwifery degree (direct entry) or a postgraduate program if you are already a registered nurse.

For an example of an undergraduate midwifery program in Australia, see Bachelor of Midwifery from the University of Technology, Sydney. This program takes 3 years of full time study to complete.

New Zealand: New Zealand also has a 3-year direct-entry program, where registered nurses can get advanced placement. From the New Zealand College of Midwives:

Each midwifery school offers an extended three year bachelor degree programme meaning that each year has a minimum of 45 programmed weeks rather than the more usual 36 programmed weeks. All students whether full time or part time must complete the programme within four years of commencement. This is the framework for all routes to midwifery registration. Each programme has a Recognition of Prior Learning Policy that enables those with appropriate previous qualifications and experience to receive credits or partial exemptions for aspects of the programme. Midwifery students who hold a previous nursing registration or those with other degrees or other relevant experience are likely to gain credit under these policies and complete a shorter programme. Registered nurses will usually complete at least two years of the full programme.

New Zealand midwifery training also includes mandatory hospital-based clinical experience:

Students work in a variety of settings over three years including family planning clinic, independent midwifery practices, neonatal intensive care units, maternity hospitals, laboratories, homebirth, and community. All students have a dedicated ‘block’ in base hospitals to achieve the experience necessary for competency in recognising deviations from the normal and working collaboratively with obstetricians in the provision of secondary care.

I was unable to find websites about midwifery in countries where English is not the first language, but according to reports from midwifery students on the studentmidwife.net forums, midwives in the Netherlands must complete a 4-year direct-entry program which qualifies them to attend both home and hospital births (and to allow women to choose to change her birth location up until the last minute without having to change providers), and midwifery school in Denmark takes 3 1/2 years to complete and midwives can do home or hospital births. Though it was a little difficult to decipher exactly what the French student midwife was saying with the language barrier, it appears that midwifery school in France is 4 years and may be part of medical school.

Okay, so, which one of these things is not like the others? All of these other developed countries train midwives to be qualified to attend births in both hospital and out-of-hospital environments and all of them require a university degree to practice midwifery. A class of midwives that deals exclusively with out-of-hospital births is unique to the United States. This raises some questions to me:

• Would requiring midwives who practice out-of-hospital to receive hospital clinical experience (where they are much more likely to encounter rare complications), make them more qualified to handle rare emergencies when they occur in out-of-hospital births?
• Would it benefit consumers for direct-entry midwives to be qualified to attend both home and hospital births and be able to obtain hospital privileges and attend the same types of hospital births certified nurse midwives currently do? Would this allow for better continuity of care when circumstances require a change in planned birth location?
• Would standardized training and education for midwives similar to what other countries do give midwives who attend out-of-hospital births more respect in the medical community, allowing for better cooperation with obstetricians, nurses, and other hospital providers?
• Would requiring more education for midwives, as some fear, "turn them into obstetricians"? Would training have less emphasis on skills needed to support normal birth with too much focus on pathology?
  

What do you think about how the training and scope of practice of midwives in the U.S. compares to the rest of the developed world?

Tempering Extremism in the Natural Birth Community

The online world of natural childbirth is often heavily influenced by extremism. People claiming things like "Birth is safe. Interventions are risky" sometimes leads women to believe that as long as there is minimal intervention in their birth and they listen to their intuition, there will be a good outcome. Worse yet is the belief that a bad outcome occured because the woman didn't "trust birth" enough or the ridiculous logic that anything makes a baby's preventable death okay.

Most people who promote natural childbirth also promote that women educate themselves, but as I have said before, the problem with not knowing is we don't know what we don't know. Many women may think that they are educated about birth when they really aren't. And if you really believe that "birth is safe," then what do you really need to know? The same is true of under-trained women who act as "midwives"--many of them follow this same mentality and are unaware of the information out there that they don't have. To be clear, I do not mean all direct-entry midwives. Some are well educated. Some are not. And having the CPM credential doesn't mean anything. Having a state license may mean something, depending on the individual state's requirements--they range from having a CPM (which, as I understand, at minimum, can be achieved by doing an apprenticeship involving at least 40 births, getting CPR and NRC certified, and passing the NARM exam) and being required to graduate from a three-year program at an accredited midwifery school, attend at least 100 births, and pass the NARM exam (Washington State).

I mentioned the homebirth midwifery laws in Oregon in a previous post. A recent tragedy in Oregon has opened debate about these laws, and many are calling for mandatory licensing. I think that this unfortunate event may be a consequence of extremism--untrained midwives thinking they were qualified enough to attend births and a poor mom who didn't know or believe that looking into their training was important.

There will always be extremists in every movement. The internet, with its power to bring people together, sometimes gives the illusion of normalcy to the extreme. Sometimes it is necessary to push back against the influence of extreme ideas--to nudge the proverbial pendulum back the other way a little. Those who do so will often be accused of being "from the other side" or "causing division." I think voices of reason are essential. I have recently come across a circle of bloggers who fight to temper extremism in natural childbirth and homebirth, and to raise standards for midwifery in the U.S. They promote Certified Nurse Midwives as the optimal caregiver for a homebirth and believe that the Certified Professional Midwife credential should be changed to match the CNM standard of education or be done away with. Amber and Jessie are both former CPM students who have now chosen to pursue CNM education. Deb ("The Sensible Midwife") is a CNM with a homebirth practice. While I may not agree with everything these women have to say, I do believe the natural birth movement needs voices like theirs to help keep it in check.

Temper (verb): to dilute, qualify, or soften by the addition or influence of something else: moderate (merriam-webster.com)

More Thoughts on Research

The comments on Homebirth Research: Another Side of the Story have been interesting. Thank you to everyone who has shared your thoughts or other information you found about the study. I think the letter to the editor from De Jonge that one anonymous commenter shared was interesting, especially the point about how the methods of data collection in the study may have inflated the perinatal mortality rate in the low risk group. If she is correct in this assessment, I believe it does call the validity of the study into question.

That said, I think that the Evers study raises a lot of questions that require further research.

• is midwifery care, with referral to obstetric care if complications arise, optimal care for low risk women?
• are there specific aspects the midwifery system in the Netherlands that are suboptimal (such as, protocols for intervals to check the fetal heart rate, as mentioned in the paper, or as one response to the study pointed out, the use of midwives assistants to watch over women until close to time of birth)?
• how might midwifery care be improved to result in better outcomes?
• how might collaboration between midwives and physicians be improved to result in better outcomes?

I think that many questions such as "Is homebirth safe?" or "Are midwives or obstetricians better caregivers for low risk women?" are questions that may never be fully answered with research. There will always be people who find a flaw in a study's design or some other way to discredit it, because most people have basic beliefs about birth that are not easily changed. There will always be people who focus (some because it is their job) on the cases where things go wrong and work their hardest to save those lives. There will also always be people who want put their primary trust in either a divine design for the process of birth or its thousands of years of improvement through natural selection (whichever is their belief, mine is these former) and who prefer to use the technology of the past hundred years or so as mostly a back-up. Most people find ways to dismiss "evidence" that does not support their basic view while accepting that which is in line with it. It is human nature.

The answer to safety in maternity care is not to convince one side that the other is "right." The answer is respectful collaboration. This is not the first time I have talked about this. In October 2010, I committed to make my blog a doctor-friendly zone, and I hope that I have held true to that promise. I believe now, as I did then, that peaceful dialogue between doulas/activists/midwives and obstetricians and other hospital providers is essential for improving our maternity care system to protect the lives and and best meet the needs of mothers and babies. I believe that hospital and out-of-hospital providers could learn a lot from each other, which I think could help improve the safety of the practice of homebirth and care in transfers, as well as improve the environment and the options available to women in hospital birth. I have started to see dialogue opening up a little more in the past months, as more physicians are creating online presences and the internet is becoming a larger platform for conversation. I'm curious also, to see where the upcoming Home Birth Summit will lead.

Homebirth Research: Another Side of the Story

Information about this has been showing up everywhere for me lately, though I have not sought it out intentionally, and I feel like I would be irresponsible not to write about it.

For a long time, I stayed away from the topic of homebirth, partly because it is such a controversial topic. I have only started writing about it recently because I am pregnant and currently am under the care of a team of homebirth midwives. My post titled "How Homebirth Benefits Babies" was the first post I wrote that "promoted" homebirth (with caveats!). It is also has been the most widely read, currently at 1,788 pageviews.

I have discovered that the evidence really is not clear on the most important point I make in that post when I talk about homebirth research. My words:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6).

It has come to my attention that the results of one of the studies I cite in that post has been called into question by the results of another study--a study that nobody in the online natural birth community appears to be talking about, even though it was published 9 months ago.

The study I cited in my post was the de Jonge study from the Netherlands, which compared outcomes of home and hospital births attended by Dutch midwives among women classified as "low risk" by the Netherlands maternity care system. De Jonge found no difference in mortality or severe morbidity in the home and hospital groups.

The Evers study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study was published in the British Medical Journal in November 2010. It compared outcomes of term births classified as "low risk" by the Dutch system attended by midwives (primary care) with outcomes of births classified as "high risk" and attended by obstetricians (secondary care). It found higher rates of perinatal mortality in the primary care group, and no difference in rates of level 3 NICU admission (the measure the study used for severe morbidity). Yes, you read that right. More low risk babies died. There were 26 delivery-related perinatal deaths out of 18,686 who began labor in primary care(a rate of 1.39/1000) and there were 10 delivery-related perinatal deaths out of 16,739 who began labor in secondary care (rate: 0.60/1000). The transfer rate from primary care to secondary care during labor was 22.9%, and 12 if the delivery-related deaths occurred in those who were transferred. The number of intrapartum stillbirths was also higher in the group that began labor in primary care. The study excluded all instances of congenial anomalies.

This study calls into question the belief that the best and safest care for low risk births is low-intervention care. From the Discussion section of the paper:

This seriously questions the supposed effectiveness of the Dutch obstetric system that is based on risk selection and obstetric care at two levels. Of major concern is the fact that the highest mortality was among the infants of women who were referred from primary care to secondary care during labour because of an apparent complication. Hypothetically, this high mortality could have several causes. Delay can occur at three moments. Firstly, diagnosis in primary care can be delayed because the midwife is not always present during the first stage of labour and fetal heart beats are often checked only every two to four hours. Secondly, transport can delay treatment in case of an emergency. Finally, a delay can occur because the obstetrician underestimates the problem as the referred woman is a “low risk” patient. In addition, essential information can be lost during the referral. These factors should be subject to further investigation, especially to evaluate whether complications with the potential to lead to perinatal death can better be predicted.

And this is in the Netherlands, where there is a universal standard for midwife education and there is supposedly to be a good system of transfer of care. Would having low risk women also be cared for by obstetricians be a better system for the Netherlands? That is basically what we have in the U.S., and we have a 33% cesarean rate. Cesareans increase the risk of maternal morality (see Deneux-Tharaux, 2006), though maternal mortality occurs much less frequently than perinatal morality does. Considering the increased risks associated with pregnancies and births in women with prior cesarean sections (see Kennare, 2007) , some of which impact both the mother and baby, I just don't see how this can be the optimal way to care for mothers and babies either. I'm not even going to try to answer the question of how many mothers (and any future babies they may have) should have to accept the risks of a cesarean section to save the life of one baby. It is something to think about.

The choices we have are between sets of risks. The absolute risk of a baby dying at all is low, especially if there is access to fetal monitoring and some level of emergency care (such as midwives who can perform neonatal resuscitation). When are talking about a rate of 1.39/1000, it means an individual has a 0.139% chance of it happening (and a 99.861% chance of it not happening)--and that's all primary care deaths in the Evers study, including ones who would have died no matter what kind of care they received. The risk of preventable death is presumably lower, though we don't know how much lower because there is no obstetrician-attended low-risk comparison group in the study. I don't want it to seem like I am trying to "explain away" the risk of preventable death. The statistics mean nothing when your baby is the unlucky one who dies. I believe in informed choice, and I believe you need accurate information to make informed choices.

After I wrote this post and was waiting to publish it (I usually space posts out further, but I moved this one up because I felt I needed get it out there), I saw this post from Birth Without Fear in my facebook newsfeed, and felt it applied to what I am trying to say. Like her, I am not here to advocate that you have a homebirth. I advocate that you look at the information, weigh your options, and make whatever is the best decision for you.

giveaway of book for birth workers

Sheridan at Enjoy Birth reviewed the book Keep the Fires Burning: Conquering Stress and Burnout as a Mother-Baby Professional by Mickey Jones, and she is giving a way a free copy! The life of a birth worker can be very demanding, and this book sounds like a great resource.

Click here to read the review and enter the giveaway!

Homebirth Set Up Video

A common question people have about homebirth is that there will be a big mess in their house and they will have to do a lot of work to clean up. This video shows a midwife setting up a home for a birth by putting a shower curtain under some old sheets on the bed and a garbage bag between pillows and the pillowcases, which helps make post-birth clean up easy. It also shows supplies for the birth, including old towels, the birth kit, and a bowl for the placenta. At the end, it shows how the midwives leave the room after the birth.

A Homebirth Midwife's Supplies

This video shows and lists the supplies typically brought to a homebirth by a licensed midwife in Washington State.

Licensing vs Decriminalization

Hope everyone is enjoying their Independence Day weekend. This post seems appropriate for this holiday, as it addresses freedom and law in the U.S.

One commenter on my post, How Homebirth Benefits Babies, said that she feels decriminalization of midwives would be a better way to legalize midwifery than licensing. I am aware of the division within the midwifery support community on the issue of licensing. Here is the issue, as I see it.

The arguments for decriminalization
Licensing puts restrictions on midwifery practice. States that license midwives have laws governing direct-entry midwifery that determine the criteria for acceptance as a midwifery client and conditions that require transfer to hospital-based care. These criteria may categorize a woman as "high risk" who is not really very high risk at all. For example, Arkansas law states that licensed midwives may not treat women who have previous cesarean sections, multiple gestation, maternal age greater than 40, or previous infant weighing more than 10 pounds. It also requires transfer for non-vertex positions and gives a set number of hours a woman can be in labor before she has to transfer. Here, in the state of Washington, transfer is required for women who pass 42 weeks gestation. I most definitely do not believe that all women that fit into these categories are only safe birthing in a hospital. These kinds of restrictions put many women and their midwives in tough situations, where the midwife could risk losing her ability to practice legally if she choses to help a woman have the homebirth they may both feel is optimal for her.

In theory, decriminalization would give midwives the freedom to set their own standards without the fear of prosecution for practicing medicine without a license (something underground midwives in states where homebirth midwifery is not legalized in any way have to deal with) and without having to worry about being punished for not following the terms of the state that gives them a license.

The arguments for licensing
The Unnecessarean reposted a discussion from their facebook wall on a status update that they shared from Big Push for Midwives'. It is an interesting conversation between midwives, consumers, lawyers, and advocates that I recommend reading if you want a good grasp of the different points of view on the issue. Here are a couple of quotes that address why licensing appears to be the best course:

Just “make midwifery legal”? How? By pushing for a blanket “midwifery is legal” law? How do you define midwifery? How do you define a midwife? How do you define what is NOT covered? All of these things would have to be done in order to “make midwifery legal.” All of these things are the same exact things done with licensure.-Tara ANaturalAdvocate

[A]s a practical matter, simply legalizing midwifery — that is, decriminalizing the practice of midwifery by statute and/or getting the legislature to pass a law to officially declare that midwifery will no longer be considered unauthorized practice of medicine or nursing — would be politically impossible. Organized medicine, and often organized brainy, fight tooth and nail against efforts by consumer groups to regulate midwifery. They win over many legislators by claiming that licensed certified professional midwives are unsafe. Can you imagine the field day the OBs and medical society would have, or how skeptical the legislators would be, if the legislation simply allowed midwives to practice without any state oversight? Even if this legislative option may have worked ever in the past, it would be truly impossible today. Really truly impossible. Our state groups are there “in the trenches” and know how difficult it is already to get licensed regulated midwives.-Susan M. Jenkins

Why push for the licensing of midwives? Because licensing legislation actually happens. Because states have the right to regulate health care providers who practice there. Because the majority of professions require some sort of license/certification/official credential to do their job. Because in order to legally recognize midwifery, you have to define it, and by defining it, you necessarily have to determine what it is not, which by definition will "limit" midwifery.

Oregon is the one state I know of were there is "decriminalized" midwifery--midwives have two options--they can choose to obtain a license from the state (which allows them to file for reimbursement from the medicaid system) or they may legally practice midwifery without a license. However, practicing without a license means it is a felony for these midwives to use oxygen and pitocin, as the use of such drugs falls under the category of "practicing medicine." I believe that women and babies benefit when midwives have the ability to legally use life-saving medications in the home in the event of an emergency. It appears to me that there is definitely a trade-off. Either midwifery involves the occasional practice of medicine, or it does not. You can’t have it both ways.

Beyond the ability to have pitocin and oxygen available, licensing also ensures consumers a minimum standard for licensed midwives. No, being licensed does not guarantee that someone is a competent midwife, but it gives consumers some indication of the midwife's qualifications. When anyone can claim to be a midwife, it creates a confusing and unsafe environment for consumers.

Licensure also strengthens the credibility of midwives, both to consumers and to medical professionals. Knowing that licensed midwives have completed certain requirements may make physicians and hospitals more respectful of them, allowing for better collaboration, which also benefits mothers and babies.

Many states do have mostly good, evidence-based guidelines for the scope of practice of midwifery. It is not necessarily licensing that limits homebirth options, but rather certain state’s licensing laws. Those who are unhappy with their state’s licensing regulations are free to organize consumer efforts to change those laws.

I, personally, am quite convinced that licensing is the most feasible way to legalize midwifery and that it helps make homebirth safer for consumers. What do you think?

Homebirth Midwifery Care Now More Accessible to Yakima Area Women

I hope my out-of-town readers will indulge my sharing some local news.

Homebirth is growing in popularity among pregnant women here in Yakima, Washington. In February 2010, KIMA news published a story about more Yakima women choosing to birth at home. Although no homebirth midwives reside in Yakima itself, the midwifery team of Kristin Eggleston, LM, CPM of Sunrise Midwifery in Prosser, and Lorri Carr, LM of Highland Midwife Birth Services in Goldendale travel to Yakima to attend homebirths. Dr. Virginia Frazer, ND, LM, of Blue Heron Naturopathic Care and Shannon Bennett, CPM, both located in Tri-cities, also attend homebirths in Yakima.

Although homebirth midwives come to women's homes for a few appointments and for the birth itself, it is more efficient for them to have women come to an office location for the majority of their prenatal visits. Until recently, Yakima women would have to travel 50 miles to the nearest homebirth midwife office for prenatal care visits with a licensed midwife. I am very excited to learn that Kristen Eggleston and Lorri Carr have recently started taking appointments one day a week (Friday) at the home of the Naturopathic Medicine and Accupuncture practice of Dr. Heidi Robel, ND, LAC, PC, located at 307 S. 12th Avenue Suite 11 (map) in downtown Yakima. This location will increase the accessibility of midwifery care for women seeking homebirth in Yakima. This may allow more women to use their services, and will make using those services more convenient for those who no longer have to travel.

How to get your partner on board with your birth plan

So, you want to change maternity care providers but your husband doesn't understand why you should go through the trouble? You want a natural birth, but your husband says, "why have pain when you don't have to?" You want to write a birth plan, but he thinks it is disrespectful to tell professionals how to do their jobs? You want to hire a doula but your husband doesn't see the benefit? Or maybe you want to give birth at home or in a birth center, but he thinks you should just go to the hospital like "everyone else"?

Here are a few ideas that might help him see why this matters to you:

• Get him to read a book, such as The Thinking Woman's Guide to a Better Birth or maybe a selected article or blog post, such as Dr. Sarah Buckley's Epidurals: risks and concerns for mother and baby or Navelgazing Midwife's Pointless Hospital "Rituals".
  
• If he is the kind of guy who doesn't like to read, have him watch a birth documentary with you. Some possibilities are The Business of Being Born and Pregnant in America.
  
• Set up a meeting for the two of you with the midwife or doula you would like to hire. She may be able to address some of his concerns.
• Get him to take a childbirth class with you. Choose a class that covers the benefits and risks of your various options, rather than one that only teaches what is standard practice at the hospital.
• Sit him down and have a heart-to-heart. Explain how much your baby's birth matters to you and why you want to be involved in the decisions about it.
  

I hope he becomes the supportive partner you want him to be. Or at the very least, he will decide to just leave the choices up to you and go along with it. Good luck!

Blurry Lines

Focus by Tomasz Sienicki

A few months ago, I read the collection of midwife stories, Sisters on a Journey: Portraits of American Midwives by Penfield Chester. I mentioned it in a previous post. I wanted to go into a little more detail about the lessons I learned from this book, most specifically about the various roles that are all part of midwifery.

Midwife as Childbirth Educator

Ideally, the role of a midwife is not just to provide medical care that is less technological than the medical model, while still being the "birth expert." The role of a midwife is to foster independence in the woman. This is evidenced by the practice of showing the woman how to dip her own urine strips and read the results herself. The midwifery practice I went to for my first couple of appointments when pregnant with my son, before we moved here, used this method. Midwifery is supposed to be about teaching the woman how to take responsibility for her own health. A good midwife will help prepare her clients for childbirth. In some respects, a midwife is a childbirth educator.

As I have read blogs by midwives discussing unassisted birth, I find it interesting that some midwives feel that having a midwife teach a UCer how to perform assessments on herself makes it not "unassisted" anymore. But where is the line between "childbirth education" and "midwifery"? If a UC mom takes a childbirth class, that wouldn't be considered "having a midwife." What if a childbirth educator taught women how to do their own prenatal and birth health care?

Midwife as Doula

Midwifery care is holistic--midwives treat the entire patient, body and mind. They believe that a woman's emotions can have a direct impact on her body's processes, and works to help her feel emotionally supported during pregnancy and birth. A good midwife is skilled in natural pain relief techniques and helps her clients use them during labor. A doula's role is said to be "mothering the mother," but isn't this also what midwives do? A midwife is also a doula.

When I wrote my post on Doulas and Hombirth, I realized that line between midwife and doula becomes blurry when you consider the possibility of a doula attending a UC. How is a doula-attended planned UC different from a planned homebirth with an unlicensed midwife? On paper, they are virtually the same thing.

Midwife as Healthcare Provider

The other role of a midwife is to observe the mother and baby for signs of problems and treat them if treatment is in her scope of practice or refer to another healthcare provider. This part of a midwife's role is similar to a physician, though her perspective on how to go about providing this healthcare is usually different than that of an obstetrician (though I would think a family practice physician might have a more midwife-like approach). And because midwives practice low intervention care and treat low-risk patients, the healthcare provider part of her role is a small part, though a very important one.

The professions of "childbirth educator" and "doula" are both relatively new because their roles were performed by midwives and their partners or apprentices before birth moved to the hospital and began being attended by physicians. The majority of physicians view the practice of medicine as dealing only with the body, not the mind, and those who are specialists like OB/GYNs are only concerned with the specific parts of the body they specialize in. Women have invented our own systems for filling the holes left in our healthcare by modern medicine, and have created the childbirth educator and the doula--and thus, the "team" of physician, childbirth educator, and doula together does all the jobs of midwifery.

Me, a Midwife?

I have recently been seriously considering the possibility of becoming a midwife someday. I have been considering the pros and cons of various paths to midwifery--ideally, I'd like to train as a midwife in another country, but I'm not sure that would work for my family. It won't happen until our own family is complete, and I feel that I won't know it is time for that until it happens. I want to be a midwife, but as I've said before, I'm quite intimidated by it. I realize, though, that what I am doing now allows women to have all aspects of their maternity care needs address (just not all by one person), so I am already helping women have care that is as close to midwifery care as they can get without actually having a midwife--to some extent, I might consider that being "part of midwifery."

Traditional Birth Secrets: The Rebozo

What is a Rebozo?

A rebozo (pronounciation) is a woven piece of fabric used by Mexican women as a shawl, a baby carrier (similar to the way I use a wrap, but the fabric is not as long), and a comfort and positioning tool for pregnancy and childbirth.

Photo by Luis Marquez
Courtesy of Special Collections, University of Houston Libraries

Rebozo Use during Childbirth

Techniques for the Rebozo in childbirth include:

• "sifting" the mother
  
• to aid in the double hip squeeze
• rocking or dangling the mother
• covering the mother's eyes and ears to block distractions
  
• for the mother to pull on, especially during pushing
  

The "sifting" technique is the most well-known uses of the rebozo in birth. It is a method jiggle a woman, similar to what Ina May Gaskin calls "shaking the apples." The motion promotes relaxation of the birthing muscles, which can aid in rotation and decent of the baby. Here is a demonstration of the "sifting" technique from a doula training:



Here is the above technique being used in at the hospital during a pitocin induction:



The technique used in the above two videos are explained more in-depth at the Spinning Babies website.

In my doula training, I learned how to do a technique called a "double hip squeeze" with my hands to open the pelvis. This video explains how to use the Rebozo to make the double hip squeeze easier:



More articles and pictures:

• The Rebozo: a transcript of a rebozo workshop given by Doña Irene Sotelo and Naolí Vinaver, published in Midwifery Today (more pictures can be seen by following the link below the photo shown)
• "Comfort Measures for Childbirth: Let's do it with a Rebozo"--a collection of images by Patti Ramos taken at a rebozo workshop with Guadalupe Trueba, including images of the rebozo used for rocking , putting it over the eyes to block out distractions, to pull on while pushing, and other uses
  
• The Many Uses of a Rebozo at Birthing Essentials--short explanations with pictures of many of the techniques
  

For more information on traditional baby carriers and rebozos, visit www.rebozoway.org.

Joseph B. DeLee: Obstetrics that Sucks

My first baby being suctioned with a DeLee Mucus Trap
Joseph B. DeLee, inventor of the suctioning device still commonly used in American hospitals today (though routine suctioning might actually be harmful), was an obstetrician in the early 1900s. In my Childbirth International workbook, I came across this lovely quote from him:

Obstetrics has a great pathologic dignity. Even natural deliveries damage both mothers and babies, often and much. If childbearing is destructive, it is pathogenic, and it if is pathogenic it is pathologic

If the profession would realize that parturition viewed with modern eyes is no longer a normal function, but has imposing pathologic dignity, the midwife would be impossible even of mention.-Dr. Joseph DeLee, 1915

Sometimes the words of Dr. DeLee are so extreme they sound like satire. They're not. The guy was serious. I first read about him in Tina Cassidy's book Birth, the Surprising History of How We are Born, which is a very easy-to-read tracing of the history of obstetrics and midwifery in the U.S.--The author of which, who had a standard hospital birth-turned-cesarean for her first birth, came out of the writing of the book a believer in midwifery, and had a HBAC with her second child (you can find the story if you dig around the archives of her blog). It was also in Cassidy's book that I first learned that a large percentage of women in the late 19th and early 20th century, including the population DeLee would have treated, were afflicted with rickets, a bone softening disorder caused by Vitamin D deficiency that often caused people to have severely deformed pelvises.

With a quick googling his name, I found that Jill at the Unnecessarian has already posted a whole series on the writings of Joseph B. DeLee:

• Joseph Bolivar DeLee and the Prophylactic Forceps Operation
• Joseph DeLee's 1915 Campaign to Eliminate the Midwife
• Joseph DeLee Warns Colleagues in 1940 About "Streamlined Labors"

Dr. DeLee was a very influential figure of his time, and his ideas were very shaping of the course maternity care in this country. The influence of DeLee resulted a wiping out of nearly all of the traditional body of knowledge about birth (luckily, a few "grand midwives" survived, mostly in the South, allowing one unbroken link to the midwifery past), and replaced it with an ideology that was not founded in science, but the belief that birth was a problem, and technology was the solution.

Obstetricians, as members of society, tend to blind faith in technology and the mantra: technology = progress = modern. The other side of the coin is the lack of faith in nature, best expressed by a Canadian obstetrician: 'Nature is a bad obstetrician.' So the idea is to conquer nature and results in the widespread application of attempts to improve on nature before scientific evaluation. This has led to a series of failed attempts in the twentieth century to improve on biological and social evolution. Doctors replaced midwives for low risk births, then science proved midwives safer. Hospital replaced home for low risk birth, then science proved home as safe with far less unnecessary intervention. Hospital staff replaced family as birth support, then science proved birth safer if family present. Lithotomy replaced vertical birth positions, then science proved vertical positions safer. Newborn examinations away from mothers in the first 20 minutes replaced leaving babies with mothers, then science proved the necessity for maternal attachment during this time. Man-made milk replaced woman-made milk, then science proved breast milk superior. The central nursery replaced the mother, then science proved rooming-in superior. The incubator replaced the mother's body for care of low-weight newborns, then science proved the kangaroo method better in many cases.
-Marsden Wagner, MD, MSPH, Fish Can't See Water: The Need to Humanize Birth in Australia

...Routine pitocin and cord traction replaced physiological delivery of the placenta, then science found a natural third stage superior for low risk women.

Science has helped American maternity care come a long way from DeLee's time, but the fact remains that the roots of our obstetric system are in the ideas of people who had a lot of things about birth wrong, at least when applied to a population of women with normally developed pelvises. I also believe he was wrong about midwives. Obstetrics (speaking of the profession generally and not of specific members) will continue to be at odds with those who support the midwifery model as long as it continues to dismiss the value of childbirth knowledge gathered by those who learn by being with woman.

Results Are In: Austrailan Study Supports Physiological Third Stage!

Back in June, I wrote about a theory paper by Australian researchers that I read that discussed the limits of current research literature that does not compare medically managed bith with truly "psychophysiological" birth, meaning unmedicated birth without routine interventions, in a comfortable setting with supportive care. This means that you can't compare the third stages of an actively managed hospital birth with a hospital birth where oxytonics and cord traction are not used, but other hospital factors are included--such as early cord clamping/separation of mother and baby, distractions, stressful atmosphere, IV fluids, unnatural positioning, etc, and claim that "expectant management doesn't work." The article proposed research that could be done comparing what they called "midwifery guardianship" with "active management."

I just learned today (thanks to Birth Sense) that the Australian researches who wrote the theory paper have completed a study on third stage management. The abstract is available here, and the results are very interesting! The study found that for low risk women, active management in a hospital was actually associated with a significantly higher rate of postpartum hemorrhage (11.5%) than the rate they found for midwife-led "holistic physiological care" in a freestanding birth center (1.7%). Considering that previous studies had found the risk or hemorrhage using other definitions of "expectant management" to be higher, these findings are important for determining what factors are necessary for a safe, natural third stage.

Birth and Death: "to mourn with those that mourn"

Today, Navelgazing Midwife wrote a beautiful post comparing the transition phase of childbirth to the transition of death. It related so much to so many other things I've been thinking about, studying, and experiencing, and inspired me to finally get those thoughts down in writing.

I have been reading my second book for the Childbirth International book review assignment (the first one inspired me to write posts on progesterone and celebrating fertility). My local library had a book that was on the list called, Sisters on a Journey: Portraits of American Midwives by Penfield Chester. Chester interviewed 27 midwives for the book, and each chapter tells one of their stories, each in that midwife's own words. I am really enjoying reading all the different perspectives. I find it inspiring, for any future midwifery aspirations I may have, but also for doula work, as it has taught me that doula-ing is actually a very large part of midwifery.

One of the common themes in the interviews is dealing with the responsibility of life-or-death situations and the possibility of death being so close. Honestly, this is something that terrifies me about the idea of becoming a midwife. I don't want the pressure to have to make such important decisions and have to act quickly and skillfully in a crisis. This book has taught me that my feelings are normal and has helped me learn how midwives may deal with that responsibility. I also learned that birth and death have a lot in common. Here is one example that stood out to me, from the interview with renowned midwife, Ina May Gaskin.

In our community, although we had never read anything about this, it was the midwives that naturally gravitated toward being with families who were dealing with death. Everyone noticed that death felt much like birth, that there was the same sort of energy--a very heightened awareness. Things and people looked dear to you; you had the sense of life being precious, of the need to be good to each other, of the need to be thankful for life, of the need to be attentive to what you had to say, of the need to mix sadness and laughter, to tell stories, to come together and be very human with each other. Not to think about money, not to think about what would anybody think.

My own baby was the first one in our community that died. I was in the first few months of my midwifery practice, exhausted and anemic, and he was born very premature and lived for twelve hours. I knew that he couldn't have been saved a the time, so we didn't go to the hospital. We did what we could, but I knew from losing him, I learned a lot. I think if it had happened to somebody else I wouldn't be a midwife now. But because I had the support of the community, I learned about grieving. I also knew that in some what that happened to teach me something important as a midwife and so I tell that story. I've learned about healing, and I learned about how you treat somebody when they've lost a baby.

(Chester, Sisters on A Journey, 1997, pg. 132-133)

That's all I am going to quote here, but Ina May also explained more about how midwives are like "gatekeepers" of birth and death, and also told the story of her daughter's death at a young age.

I recently saw the film The Curious Case of Benjamin Button, and though I found the film very long and the ending, sad, I learned the lesson I think it was trying to teach--growing up and getting old are really the same, just in opposite order, and life is really more of a circle than a line. Based on this perspective, birth and death are basically the same.

October 15th was Pregnancy and Infant Loss Remembrance Day. As I lit my candle that evening, I thought of my friend who lost her baby in her second trimester recently. I was very affected by the loss, since we had discussed her preparations for the birth and I had offered to serve as her doula. I found I needed to cry alone about it, and I don't think I would have anticipated that happening.

Last week I learned that my high school U.S. History A.P. teacher, now retired, was killed in a car accident while traveling in Greece. She was my favorite teacher, an entertaining storyteller whose love of history really shined in her teaching. She was an inspiration, the kind of educator I aspire to be. Any time such a vibrant person leaves this world, it kind of brings you face-to-face with your own mortality.

Through all of these experiences and learning, the following passage from the Book of Mormon has been on my mind:

...and now, as ye are desirous to come into the fold of God, and to be called his people, and are willing to bear one another’s burdens, that they may be light;

Yea, and are willing to mourn with those that mourn; yea, and comfort those that stand in need of comfort, and to stand as witnesses of God at all times and in all things, and in all places...(Mosiah 18: 8-9)

These verses represent the covenant one makes when joining our faith. Interestingly, the last part of it is quoted in the document I wrote about in my Guest Post at the Gift of Giving Life. It is the part before that which I have been thinking about, especially "to mourn with those that mourn." If we have charity and love others as God loves them, we will have the desire to support others through their journeys in life. This includes things like crying with someone who is in the middle of grief. I have been thinking that maybe working with pregnant and birthing women, in the fragile time of newly developing life, who will sometimes not keep that life as long as we all would want them to, will be my personal way to fulfill my promise "to mourn with those that mourn."

Physiological 3rd Stage, without the "as long as..."

I shared a link to my post A Natural Third Stage with Buscando la Luz after reading two posts on her blog, Birth Faith, called Preventing postpartum hemorrhage naturally and Preventing Postpartum Hemorrhage: a follow-up. She shared it on her facebook page and my live traffic feed has been going crazy with hits to that post. One commenter was a former L&D nurse who said her experiences backed up the theories I wrote about.

If it is true that keeping mother and baby together reduces the risk of hemorrhage, then that is a good reason not to cut the cord immediately. According to Dr. Nicholas Fogelson of AcademicOBGYN,research does not support the current standard practice of immediate clamping. (I also love this post also because of his example of routine episiotomy as a practice that is very obviously passe. I know from a first hand conversation that there are some dinosaur OBs out there who don't stay up to date on research who still use them liberally--I should post about that conversation sometime)

Someone on the Childbirth International e-mail group recently shared a link to a beautiful series of birth photos by Patti Ramos called Emergence. One of the photos shows an attached cord that is simply beautiful. I never knew they were that color.

Later timing of cord clamping may better for both mother and baby. However, after two hospital births where clamping occured earlier than I preferred both times, I have come to believe that physiological cord clamping is still quite rare in hospitals. I think this is partly because they have been conditioned to believe that routine immediate clamping is normal and may subconsiously look for a reason to cut the cord, partly because they have narrow parameters for what constitutes a "healthy" newborn and are quick to provide support, and partly because they aren't set up to provide transitional support to neonates without moving them away from their mothers. Often "delayed" cord clamping is only available at special request and "as long as the baby is doing okay."

In a post at her blog Midwife Thinking, The placenta--essential resuscitation equipment, one homebirth midwife discusses her reasoning for keeping cords intact no matter what and explains how she goes about doing that. She also talks about obstetric pracitces that contribute to the need for babies to be given support. In a response, Navelgazing Midwife shared pictures of the wooden board she brings to births so that she has a hard surface she could use without cutting the cord in case she ever needs to do chest compressions on a baby.

This just goes to show that in some things, both your choice of provider and the equipment aviailable in your chosen birth location can influence what happens in your birth.

Painless Childbirth, revisited

Lately, my Understanding "Painless" Childbirth post has gotten a lot of attention. I'm so glad, because much of what is in it is so important for women to know. I have gotten a few comments from women who experienced painless childbirth without hypnosis. I think these stories are awesome and they fit right in with the ideology that birth doesn't have to be painful. Here is one of the comments, explaining the various degrees of comfort for her five births.

[. . . ]I experienced almost painless childbirth with and without drugs and never used hypnosis. I think it is different for everyone..[. . . ]In five births, number one and two were painless with drugs. Number three was painful. Number four was not painful until the last ten seconds and number five was painless

I just started focusing on reassuring the baby and the surges never got painful with four and five. The crowning was not painful on number three and number five.

The contractions hurt on number three (possibly because I was panting to keep the baby in on the dash to the hospital.)

Notice her theory that fighting against what her body wanted to do in order to get to the hospital before giving birth may have caused more pain that was necessary. I have been meaning to write about why I feel my second birth became uncomfortable during second stage, after I was almost completely comfortable for first stage, including transition.

My birth plan said "limit vaginal exams to those I request, unless necessary for a medical decision." This request was ignored soon after my OB started to tell I was getting pushy. She had me get into a good position to be checked (big mistake #1 was getting into that position in the first place, big mistake #2 was not getting out of it) and when I was found to have just a lip of cervix left, she continued to check periodically without saying anything. I didn't really mind much at the time since I was really focused on relaxing through the waves, but I do understand why some women feel violated by things like that. I had read about the flaws of the rule of 10 and wanted to be able to push a little if I felt like it even though I was not "10 centimeters." At first, my OB's advice supported this, and she encouraged me to push only as much as I felt I had to. The waves felt different and I began to vocalize through them, because it felt better to, but I was still using my hypnosis and staying comfortable. I don't know how much time passed, but she must have gotten impatient, so she wanted to try holding back the lip of cervix and having me push, which was extremely uncomfortable.

All of you who work with birthing women, this is important, during birthing, our brains sometimes don't clearly interpret what you mean when you say things to us. When trying to hold back the lip of cervix didn't make it go away, my OB told me to try not to push, though I think now she must have meant to only push as much as I had to, but in my confused birth-brain, I read it as "don't push at all" which was very different from what my body was telling me to do, and I think greatly increased the discomfort and, I dare say, pain that I experienced. It is likely that the fighting my body and the confusion caused the pain, not necessarily the pressure waves. When she started telling me I could push, obviously that implied the lip was gone, but again, I had birth-brain. This (and not getting out of that bed) is why I think I ended up needing to be coached to push him out. Once I started really pushing, it wasn't really painful anymore. Crowning didn't really hurt to me either, just felt like really intense stinging.

Here is another comment from a woman who experienced a painless birth:

I had a painless birth with my fifth baby. It was so painless that I didn't realize it was real until he was crowing. (Luckily my husband recognized subtle changes in my mood and called the midwife, who arrived just in time.)

I did not do hypnosis. I just practiced relaxing my perineum with each braxton hicks. When I was lying in bed, in active labor, I thought I was having BH contractions so I just kept relaxing my perineum.

It didn't even hurt when he was crowning. I tore a little and that stung but not bad at all.

For the record: My son was 10lb 6oz and I have a ridiculously low pain threshold

That is pretty amazing. Her comments illustrate beautifully that women do not have to have an unusually strong ability to endure pain to have enjoyable natural birth experiences--it is not an issue of how much pain you can take, but how you choose to think about the sensation you're experiencing.

In both this story and the previous, the moms did not have the painless experience until they had already been through birth before. These women have probably found a solution to the fear problem by experiencing birth. Since they have done it before, they don't need to fear the unknown. Thinking you're not really in labor would probably reduce the fear, too.

Here is another one, from a midwife

[. . .] I had painless childbirth with all my babies. I think it was because I did unassisted births and no one talked to me or touched me while in active labor. I was able to go into the zone and time seemed to stand still. But every time I looked at the clock an hour had gone by. When it was over I felt like I had just had the best sex ever. I was 17 and had a 5 and 1/2 hour labor with my first.

As a midwife, I try to allow my moms to go to that zone, but I also have to listen to the baby, give drinks of water, etc. I tell my apprentices not to talk to her, just support as they see a need and be aware of the mom's response.

I have discussed unassisted birth before. I do think that women are likely to have more comfortable birth experiences if they can be undisturbed. Undisturbed birth does not necessarily have to be unattended. If a doctor or midwife can act as a lifeguard, then a "best of both worlds" birth is possible. The benefits being able to stay focused and follow your instincts while still having a knowledgeable expert available to step in if they are needed. This appears to be how this midwife practices and teaches her apprentices to practice.

How Midwifery Care Can Reduce Racial Disparities In Birth Outcomes

At the request of Courtroom Mama posting at The Unnecessarean, I watched the documentary Crisis in the Crib: Saving Our Nations Babies. I think the film does a great job of raising awareness on the issue of racial disparities in birth outcomes and infant mortality in the United States. It really got me thinking about what factors contribute to this disparity. I think it is a very complex problem, and it can be difficult to pinpoint all of the causes. Poor nutrition, lack of exercise, and lack of access to care are all factors, but they don't explain why there is still a disparity for babies of college educated black women. The film suggests higher stress levels and the lack of presence of a supportive partner as possible additional factors that could influence middle class populations. There are also some life-course factors.

As I was considering these factors and trying to decide what to write this blog post about, I remembered this video from last year's The Big Push for Midwives Issue Briefing for members of Congress showing Jennie Joseph, LM, CPM talking about her birth center, The Birth Place, in Orlando, Florida.

It's pretty clear that The Birth Place has drastically fewer racial disparities than her area's average. She attributes the difference to their care being more accessible to the uninsured, but I think that is only part of the story. I believe that the obstetric model of care, which is the norm in the U.S., is failing black women. Here are some components of the midwifery model that I believe may better meet their needs:

• Focus on Preventing Complications with Healthy Lifestyle - While obstetric practices generally focus mostly on screening for pathology, midwifery care includes extensive counseling on nutrition and exercise during pregnancy. This approach integrates prevention of problems.

• Individualized Care - Midwives strive to make their care specific to the needs of individual women instead of providing one-size-fits-all care that may be more suited to one race than another.

• Holistic Treatment - Midwifery care treats the whole woman, not just her body. Prenatal care that is only a medical check up is a missed opportunity to resolve other issues that could contribute to disparities, including social and emotional stresses in the woman's life.

• Longer Prenatal Visits - The average length of a midwife visit is significantly longer than one with a physician. This allows more time to focus on these issues and develop a trusting caregiver/client relationship.
  

• Relaxation Practice - Birth centers do not offer epidurals, so midwives at a birth center would encourage women to prepare for a natural birth. In fact, State of Florida Law requires that birth centers counsel their clients to receive appropriate childbirth education. This preparation usually involves relaxation practice, which can be helpful for dealing with stress.

• Empowering Education - Midwifery supports women in being educated and involved in decisions about their care instead of letting the birth professional make most of the choices for them. This can help them learn to take responsibility for themselves and their babies, both during and after the childbearing cycle.

I believe that the caring, sensitive, woman-centered model of midwifery care may be exactly what is needed to reverse the terrible trends we see in maternity care today and make great bounds in resolving the disparity we see between races in maternity care in the U.S.

In honor of International Day of the Midwife

In addition to being the day Mexico celebrates their independence, May 5 is also International Day of the Midwife. In honor of the day, I'd like to share the link to the story of Puah and Shiphrah (from the book of Exodus) on Heatherlady's Women in the Scriptures blog. I love how the midwives in the story couldn't go against their divine responsibility to protect mothers and babies, even if it meant going against Pharaoh's orders.

I credit the nurse-midwife I had for my daughter's birth with helping me avoid an unnecesarian.

Does anyone have any good midwife stories to share?