As Dear to Life As Breathing*

One of the doctors from our hospital spoke on a local radio program last evening, albeit briefly, on the issue of Licensed Midwives in California having the right to practice without supervision by a physician.  You can hear the piece on the KALW program Crosscurrents. I posted the piece to Facebook with the request for people to share opinions, a wildly regrettable move on my part, always, because that forum appears to be for a  large majority of people who peruse (i.e. express impressionistic reactions) and who do not read.  But the great thing about radio is that if you're not a reader you can be a listener and you can do that here.

The crux of the story is one that lays out all of the apparent advantages of legislation known as AB 1308 (which also requires reading).  Admittedly, the proposal was explained fairly accurately in the Crosscurrents piece.  The big omission was the differentiation between Licensed Midwives and Certified Nurse Midwives and the conflation of CNMs with Obstetricians who practice inside the hospital.  That and the rather big assumption that all pregnancies and births are low risk and therefore all women are, by default, candidates for home birth. These issues definitely remain firmly stuck in my craw. Every day. It is irresponsible for us, as healthcare providers in obstetrics and women's health, to let women believe that prevention is akin intervention.  It is equally irresponsible to guilt women into thinking there is a "right" way to experience birth and to become a mother.  Childbirth and motherhood are hard enough.

But what we're talking about here is AB1308.  Current legislation allows Licensed Midwives at alternative birth centers to practice under a Physician or a Certified Nurse Midwife.  This distinction was not clear in the Crosscurrents piece.  In 2010, there were 1,500 Certified Nurse Midwives in practice in the state of California, many of whom practice homebirth exclusively.  Very few, in fact, are hospital-based providers. CNMs are educated and trained under a medical model, equipping them with strong clinical skills by way of training as advanced practice nurses.  CNMs must be registered nurses and must receive a master's degree in a nurse-midwifery program that is accredited by the American College of Nurse-Midwives in order to practice legally. These midwives can treat patients throughout their pregnancies, attend births, prescribe medication and are highly trained in the pathology and physiology of childbirth to be able to recognize a women or baby who may be in distress and in need medical intervention, a real and unfortunately common occurrence.  (Consider maternal and neonatal mortality rates in parts of the world where medical intervention is *not* accessible).  Licensed midwives, on the other hand, may or may not have a bachelor’s degree and their training varies depending upon length of apprenticeship, mentorship and at home study.  I think making this distinction is central to a conversation about the role of midwives in the community and what AB1308 means for the profession of Midwifery as a whole.

Of the responses I received to this post, most didn't even address the point of the radio piece.  Many made the fallacious argument that a midwife-attended "homebirth is (statistically proven to be) more  safe than a hosptial-based birth" -- an argument I can't deny (not unrelated, I am sure, to the fact that it was the basis of my senior thesis as an undergraduate.) But it's a poor logical argument, a base rate fallacy.  Statistically, outcomes for homebirths are quite positive.  This is true.  Personally, I fully support and advocate for homebirth with a Certified Nurse Midwife under the condition that both mom and baby are in good health.  But the statistics of it are somewhat confounding.  I am hesitant to embrace statistics comparing midwifery to hosptial-based care because it is fraught with problems - in that there are certain variables for which there is no control. For example, high risk patients are treated in hospitals and have "worse" outcomes (higher rates of epidural use, episiotomy, vacuum or forcep extraction, neonatal admission to the NICU, maternal blood transfusion, cesarean section).  All because hospitals have access to these interventions and treat sicker patients.  This is fact.  Providers in medical settings have the tools and the knowledge to manage extremely difficult situations and to keep babies and mother's alive.

I guess the question always lurking in the back of my mind is "how many bad outcomes would I, as a practitioner, accept?" (A bad outcome, in my mind being a maternal or neonatal death, not a cesarean section).  For me, personally, the answer is zero.  I wish I had, in my lifetime, seen zero.

The confusion between high and low risk birth, maternal right and choice, information and knowledge, security and safety is complicated.  It is complicated by history, complicated by access, complicated by perceived understanding, complicated by stories like these and specifically by women who stake claim over what is right for other women in the name of liberation.  I have said this before and will say it again: Prevention of poor maternal and neonatal outcomes, or death, should never be mistaken for unnecessary medical intervention.  It is so disheartening to me that obstetrics has become this strange and difficult place for feminist convergence and collision and thus is the ONE area of healthcare in this country where preventative medicine is shunned as counter to choice.  When the outcomes are poor, it is also the most litigious area of healthcare.  And in these cases it is the most heartbreaking because it is here that we have the most to lose.

If women lose the right to say where and how they birth their children, then we will have lost something that's as dear to life as breathing. - Amy McKay, The Birth House