CHILDBIRTH

I thoroughly enjoyed reading the Winter Alumnae Bulletin. I am wondering if you might be interested in gearing another Alumnae Bulletin to choices in childbirth or birth stories. I have noticed that an increasing number of BMC graduates are choosing midwife-attended home birth, including myself. I recently became President of Friends of Midwives in Connecticut and have embarked on a public education campaign that will eventually lead up to proposing a bill in CT pertaining to the licensure of Certified Professional Midwives (CPMs), who attend home births almost exclusively. I am attaching a couple of things I have written for your consideration. The first is a copy of NOW's recently passed resolution on midwifery. The second is a letter I wrote to Patricia Ireland thanking her for that resolution. The third is an article I have written for CT NOW's Winter newsletter called "The Waterfall" which explains what makes the midwifery model of care a feminist/woman-centered model of care we should fully support and promote in this country and in my state.

—Sharon Stankevich Reilly '91


National Organization for Women

National Conference
Committee on Health and Reproductive Rights

July 3, 1999

NATIONAL ORGANIZATION FOR WOMEN EXPANDS DEFINITION OF REPRODUCTIVE FREEDOM TO INCLUDE MIDWIFERY MODEL OF CARE

WHEREAS, The National Organization for Women has long supported reproductive freedom as a priority issue; and

WHEREAS, NOW believes that women should have compete authority over their reproductive lives; and

WHEREAS, reproductive freedom not only includes the ability to decide whether or when to bear children, but also the right to devise a birth plan with a medical provider of their choice in either a hospital or an alternative setting such as a freestanding birth center or private residence; and

WHEREAS, women have historically given birth with midwives; and

WHEREAS, the practice of midwifery has many benefits including lower costs, lower rates of premature births, higher rates of breastfeeding; and greater satisfaction with the birthing experience, and has been endorsed by The World Health Organization; and

WHEREAS, midwifery has a lower incidence of medical interventions during the birthing process, including routine episiotomies and Cesarean sections; and

WHEREAS, women's access to midwifery and traditional birthing practices are many times limited by restrictive laws and non-coverage by private insurance companies and state-subsidized funding;

THEREFORE, BE IT RESOLVED that The National Organization for Women's policy statements, brochures and fact sheets on reproductive freedom shall include references to birthing choices, safe childbearing practices, midwifery; and

BE IT FINALLY RESOLVED that NOW work in cooperation with state and national midwifery organizations to increase women's limited access to midwifery and community awareness of childbirth, pregnancy and early parenting choices.

Submitted by: The Health and Reproductive Rights Hearing of The National Organization for Women, National Conference, Beverly Hills, CA July 3, 1999, Chair: Shiela Moore. Ratified at conference.


Ms. Patricia Ireland
President
National Organization for Women
1000 16th Street NW, Suite 700
Washington, DC 20036

Dear Ms. Ireland:
Thank you! I was absolutely thrilled to learn about NOW’s recent ratification of an expanded definition of reproductive freedom to include choices in childbirth (July 3, 1999). I am even more excited over the prospect of NOW’s working together with state and national midwifery organizations to promote childbirth choices and the midwifery model of care.

As a graduate of two women’s colleges, I have a strong interest in feminism. In the process of becoming a mother, I discovered that there are a number of feminist scholars and midwives who have made issues surrounding childbirth their life’s work: Barbara Katz Rothman, Rahima Baldwin, Robbie Davis-Floyd, and Nancy Wainer Cohen, to name a few. Thanks to them, and with the encouragement of midwives, I managed to fight for and give birth to a perfect breech daughter without being knocked out cold, cut in half, or delivered an injured newborn in the process. My husband called me a pioneer that day, and one of the obstetricians (a woman) even admitted to me, "We perform entirely too many C-sections in this country and your birth proves that they are just not necessary." Achieving an anaesthetic-free, scalpel-free, vacuum-free childbirth with a breech baby is no insignificant feat for a first-time mother.

Three and a half years later, my second daughter was born at home with midwives. Both of these pregnancies and births were empowering, but the second was positively cathartic. It was so different and so profoundly wonderful. For one thing, I had continuity of care throughout pregnancy, birth, and beyond. There was no hopping from doctor to doctor, explaining over and over again what I did and did not want and arguing the fine points of why; there was no switching from shift nurse to shift nurse, or obstetrician to pediatrician. My midwife continued to provide care for my baby, not just me, in the weeks following her birth. And she came to my house – I didn’t even have to get up out of my rocking chair, much less load two kids in and out of car seats and to and from various offices. At my last post-partum checkup, my midwife asked, "Is there anything else?" Instead of simply enjoying my new baby, I had become enraged. Amid an unexpected burst of tears, my response was, "Women are being robbed. They have no idea what childbirth can be like…They are just being robbed and they don’t even know it." That day I promised myself I would devote the rest of my life to helping women achieve healthier pregnancies and better births.

Why should the personal events of one woman’s life be of any importance to NOW? Because I am a feminist, community activist and educator, research analyst, mother of two daughters, and aspiring midwife and scholar who, with other childbirth activists, needs the support of NOW. With this resolution and the program of action based upon it, the organization is now in a position to meet my needs as a mother and the needs of the countless victims of obstetric violence. The episiotomy rate for first-time mothers is 95% in the U.S. We have got to put an end to the almost mandatory practice of cutting open women’s vaginas with a knife during childbirth. That one out of every four babies in America is born via C-section, is also an example of violence against women. As the NOW resolution notes, midwifery and home birth could dramatically improve maternal and infant mortality and, equally important, morbidity, in the United States. Other countries have successfully integrated these into their maternity care systems. Why can’t we?

NOW demonstrates with this resolution that feminism and motherhood need not be mutually exclusive. All of us stand to benefit from this welcome change. I am therefore re-joining NOW after more than 10 years of non-membership. With enthusiasm, I volunteer to assist the organization in "working in cooperation with state and national midwifery organizations to increase women's limited access to midwifery and community awareness of childbirth, pregnancy and early parenting choices". I will contact my local NOW office and midwifery organizations to assist with possible actions toward this end in Connecticut. Thanks again!

Yours truly,
Sharon Reilly


Reproductive choice not only includes the right of every woman to choose whether and when to have a child, but also to choose where and with whom she gives birth. When a woman chooses to give birth at her home, she requires the care of a practitioner whose training and experience pertain specifically to home birth. "Independent" or "traditional" midwives, are such practitioners. In order for women to maintain their right to choose where and with whom they give birth, the state needs to take steps to ensure that independent midwives remain accessible to the Connecticut families who choose home birth. Making independent midwifery accessible includes licensing, and opens up the possibility of third-party reimbursement for services.

Who are the women in Connecticut who choose midwife-attended home birth, and how do the services and training of their midwives differ from those provided by obstetricians and nurse midwives? Currently, the 1% of Connecticut’s childbearing women who chose home birth are serviced by ten independent midwives and one nurse midwife. The only characteristics that might distinguish these women from other childbearing women are their knowledge of or interest in the birth process, their desire to take an active role in their care, and their willingness to take on greater personal responsibility for their health and in planning for the birth. Why do they choose home birth? Mainly for two reasons: first, the Midwifery Model of Care (described below) is more woman-centered and mother- and baby-friendly than the Obstetric/Medical Model of Care; and second, research across the globe has shown that home birth with a skilled, experienced midwife to be as safe as, or safer than, hospital birth (Stewart 1997, Tew 1990).

Some Childbirth Statistics
In the U.S., 99% of all births take place in the hospital; 92% with a physician (CDC 1999). The U.S. ranks 25th internationally in infant mortality (NCHS 1993). In every Western industrialized country with a lower infant mortality rate than ours, midwives are the primary caregivers for at least 70% of childbearing women (Suarez 1993). Worldwide, no research has ever shown hospital birth to be safer than home birth. In fact, a recent analysis of over 800,000 births in California has shown the opposite to be true: neonatal and maternal outcomes for home births attended by non-nurse midwives are equivalent to hospital births; however, home births have significantly lower intervention rates for both mothers and newborns, and greater satisfaction with the birth experience among mothers even in the absence of pain medication. This is true even when one controls for such factors as class, race, education level, insurance status, or maternal age (Schlenska 1999).

The Midwifery Model of Care
What distinguishes the midwifery model of care from the medical model of care? The midwifery model of care is premised on the belief that pregnancy and birth are, in the vast majority of cases, normal, healthy, physiological processes with significant psychological and sociological dimensions for both the mother and baby. The midwifery model of care is characterized by: continuity in the relationship between the woman and her midwife throughout the childbearing cycle, minimal use of technology and technological intervention, education of the mother about self-care and birth during the prenatal period, emotional and hands-on support during labor, and care of the woman and newborn dyad following birth. Perhaps most importantly, the midwifery model of care sees the needs of the baby and the needs of the mother as inextricably linked: if you focus on taking care of the emotional and physical needs of the mother, the baby’s health and development will be maximized.

The medical model of care is premised on the belief that pregnancy and birth pose risks to the mother and baby from which they both need to be protected. The medical model of care is characterized by: a high level of technology use during pregnancy and birth (such as ultrasound, continuous electronic fetal monitoring, the administration of intravenous fluids during labor) and intervention (such as pain medication, labor inducing or augmenting medication, episiotomies); little or no emotional or hands-on support during labor from the primary practitioner until birth is imminent; and post-partum care provided by separate physicians: an obstetrician for the mother, a pediatrician for the newborn. With this model of care, the mother’s and baby’s needs are viewed as separate and, frequently, at odds with each other (Rothman 1989, Davis-Floyd 1992).

Thus, the midwifery model of care is a woman-centered model of care. It is a model of care that supports women’s decision making power, that welcomes both informed and intuitive self-analysis, and that educates and empowers women to care for themselves. In so doing, the mother maximizes the growth and development of her own baby. With this model of care, the woman, respected as the sole owner of her body and her own best expert on its functions, gives birth to her own baby. Her baby is not "delivered."

Striking a Balance for the Benefit of All Women
This is not to say that all physicians fail to embrace the midwifery model of care, nor that there aren’t times when medical intervention is appropriate and necessary. Increasingly, OB/GYN and family medicine practices, often those run by women, are including midwives (typically nurse midwives) in the care their offices provide to parturient women. Indeed, there are some doctors who practice the midwifery model of care, just as there are some midwives who practice the medical model of care.

Midwives ideally practice in a collaborative relationship with obstetricians, particularly to meet the needs of the 5-15% of women who require medical referral during pregnancy or medical intervention for a complicated birth. In this regard, one might consider midwives as appropriate caregivers for the majority of women but who make referrals to obstetric specialists whenever necessary. This is how maternity care is provided in almost every other developed nation in the world. In the U.S. and in Connecticut, we must try to strike the balance that other Western industrialized countries have: a maternity care system in which both midwives and physicians practice in their own right, together providing a broad spectrum of care that caters to the needs and desires of all women.

Political Issues
In Connecticut, current legislation regarding midwifery pertains only to the scope of practice and licensure of Certified Nurse Midwives (CNMs). CNMs get their training either concurrently with or after completing their training as nurses. They are legally required to work with physicians and generally practice in hospitals or birthing center settings. The American College of Nurse Midwives (ACNM) sets the standards for nurse midwifery education and credentialing. Nurse midwives may practice legally in all 50 states.

Distinct from CNMs are independent midwives, many of whom are Certified Professional Midwives (CPMs). They train in midwifery through a variety of educational routes including midwifery training programs, apprenticeships, self-study, and university coursework. CPMs earn their certification through the North American Registry of Midwives (NARM) upon passing a written exam and a hands-on skills assessment designed to evaluate a wide range of competencies. Importantly, to achieve the CPM credential, a midwife must demonstrate knowledge and expertise specific to home birth. That is not the case with CNM training and certification.

To provide appropriate care for the full spectrum of choices a birthing family may make, Connecticut needs both nurse midwives and independent midwives. Analogous to the state’s current licensing of CNMs, which is based on the credentialing standards of the ACNM, the state should develop a licensing program for CPMs that is based on the credentialing standards of NARM. Such an approach would avoid unnecessary regulatory costs and burdens on the state, and would ensure that a professional organization most qualified to evaluate independent midwives does so.

This approach is suggested by the Alliance of Connecticut Midwives (ACM) and two consumer groups in Connecticut that exist for the purposes of educating the public about midwifery, advocating for consumers, and taking political action on behalf of midwives (both CNMs and CPMs): Friends of Midwives in Connecticut (FOMinCT) and United Families for Midwifery Care (UFMC). These organizations would like to enter into discussion with Connecticut NOW regarding possible legislative efforts. If you are interested in learning more about midwifery, helping with public education activities, or assisting with legislative issues, please contact Sharon Reilly, President, Friends of Midwives in Connecticut (Home telephone: 860-688-4703, E-mail: reillyassoc@home.com), or visit our website. Your show of support for independent midwifery is nothing less than a show of support for woman-centered, pro-family reproductive choice.

For further reading:

Suzanne Arms Immaculate Deception II (1994)

Robbie E. Davis-Floyd Birth as an American Rite of Passage (1992)

Barbara Katz Rothman Recreating Motherhood: Ideology and Technology in a Patriarchal Society (1989)

Peter F. Schlenzka "The Safety of Alternative Approaches to Childbirth" (unpublished Ph.D. dissertation, Stanford University, March 1999, available on the Internet via www.cfmidwifery.org)

Suarez, S.M. "Midwifery is not the practice of medicine" Yale Journal of Law and Feminism 5, 2 1993

David Stewart The Five Standards for Safe Childbearing (1997)

Marjorie Tew Safer Childbirth? (1990)

Marsden Wagner Pursuing the Birth Machine (1994)

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