For CALM ~ Part 1: Background to prevent passage of inappropriate regs; legal & political arguments — extensive Hx quotes-excerpts

The “bad old days” for childbearing women and midwives are right here and right now!

This post provides information and strategies to prevent passage of statutes or regulations that are “disguised restrictions” on the provision of midwifery services or function as a “denial of services” to childbearing women.

We are still living with the regressive and repressive obstetrical practices that came into style 100 years ago.

It’s easy to get depressed over this long travesty of justice, but we must remember that the 1950 Noble prize in medicine was awarded to the doctor who “invented” the frontal lobotomy as an effective treatment for mental illness and epilepsy.

But medicine as changed greatly since then and today any doctor who did lobotomy would lose his or her license.

Nonetheless, she persisted!
We will eventually right this historic wrong!

• VBAC care by Ca LMs versus mandated regulations proposed by ACOG
• Strategies and presentation tools/talking point to avoid inappropriate regulations
• Legal & philosophical arguments if it become necessary to file an Amicus Brief w/ the OAL

For VBAC women and their families,  mandated physician-obstetrician evaluation is an unmitigated abridgment of customary patient-rights of autonomy and self-determination by mentally-competent adults, who have a recognized legal right to receive full information about any proposed medical treatment or services, and to freely consent or decline this medical care under non-urgent circumstances.For women seeking VBAC, adding VBAC to the regulatory list mandating obstetrical referrals, evaluations and approval is an unworkable idea from many perspectives.

• Regulations mandating physician evaluations for VBAC and several other categories  also impose a disguised restrictions on services that for many women also represents a denial of services, the consequence of which will be inadequate prenatal care, unattended labors and for a small number, unattended births. (see 1984 AJOG study describe below).
• For Ca-LMs, mandated obstetrical evaluation for VBAC women establishes a legal process that is an on-going restraint of trade and unfair business practices.
• For taxpayer who underwrite the Medicaid-MediCal program for qualifying low-income families and California businesses that underwrite employee health insurance plans, this policy greatly increases the cost of care.

Taken together, the effect of the 2013 amendment to the Licensed Midwifery Practice Act of 1993 (LMPA) is directly in contradiction to the LMPA’s Legislative Intent, which was to make maternity care MORE available to women who otherwise would not have quality prenatal care and professional childbirth services.

It’s shocking to realize that California’s midwifery licensing law now include a provision to keep professional midwives from legally providing maternity care to this subset of childbearing families.

Preamble to Effective & Affordable Maternity Care in the US: 

Do we believe in the wise use of our maternity care resources, defined as the ‘right use’ of obstetrical services for women with high-risk conditions and complications and the ‘right use’ of physiologically-based care for healthy women with normal pregnancies, usually provided by professional midwives and family practice physicians.

Do the citizens of California believe that healthy childbearing women and their unborn/newborn babies should have regular access to high-quality, cost-effective maternity care, including the supportive and non-interventive care of midwives? This is a far more humane system for healthy mothers and babies and orders-of-magnitude more cost-effective for California taxpayers than the highly-medicalized system that is the current obstetrical standard of care.

The routine use of the highly-interventive and extremely expensive obstetrical model for essentially healthy women is medically inappropriate and unproductively expensive. This highly-medicalized obstetrical system exposes approximately three million healthy mothers and babies to unnecessary risks such as the danger of medical errors and hospital-acquired infections, as well as the many delayed and downstream problems associated with our high C-section rate.

The answer to this question would have been expressed simply by our grandfathers’ generation as “the right tool for the right job“. When sawing wood and pounding nails, it will always be a ‘wrong use’ of a saw to attempt to pound nails with it or wrong use of a hammer in attempts to cut wood.

The right tool for the right job is the one that does the most good and results in the least harm. When it come to pregnancy and childbirth supportive physiological care provided by professional midwives in healthy women — 70-85% of all the childbearing population — and obstetrical management for those with (a) high-risk pregnancies, (b) who develop complications and women who request medicalized care after being fully-informed of its risks and possible side-effects.

General legal background per AB 1308 as it applies to the mandated physician referral of midwifery clients with certain identified risk factors, while eliminating the normal professional process of consultation by midwife with other midwives, nurse-practitioners, and physicians including in specialties other than obstetrics:

According to AB 1308, childbearing women receiving care from California licensed midwives must be immediately referred to a medical doctor with training in obstetrics if any “deviation from normal” is detected during the pregnancy, childbirth or postpartum. This type of mandatory referral also applies to certain risk-factors and other conditions that at some future time will be identified in regulations.

Under the 2013 amendment to the Licensed Midwifery Practice Act of 1993 (LMPA), a physician-obstetrician is to examine the pregnant woman and determine whether the condition in questions is or is not “likely to affect the client’s pregnancy or childbirth”.

It should also be noted that many pregnant women have non-obstetrical reasons for physician evaluation. In those cases the most appropriate medical referral may be the patient’s primary care provider, a physical therapist, or a specialist such as an endocrinologist or perinatalogist.

Nonetheless, AB 1308 requires all midwifery clients to first be seen by a “physician and surgeon with training in obstetrics”. Since study of obstetrics in California medical schools is an elective subject, the vast majority of MDs with obstetrical training are actually board-certified obstetrician-gynecologists. This means the mother-to-be must first see an obstetrician and pay for that consultation before she can be referred to her primary care provider, perinatalogist, etc.

An even bigger problem is lack of any definition or metric guidance in AB 1308 relative to the terms: ‘deviation’, ‘likely’ or ‘affect’. This crucial determination must be based on each individual examining physician’s interpretation of these concepts.

Honest differences of opinion within the healthcare field are a well-known and common phenomenon; one practitioner may see only a minor variation of no immediate concern, while another is convinced that the same condition warrants immediate medical intervention.

The only rational method for making such a determination is the clinical judgement of the midwife providing care. As the primary care provider, the midwife is best suited to parce the difference between variations and clinical significance deviations under the specific circumstances of a particular pregnant or laboring woman.

The term ‘likely’ is a word that denotes ‘comparison’ with something else that is specified — ex. more likely to rain on a cloudy day than a sunny one. But without identifying the object of comparison, each individual is required to interpret the concepts of ‘likely’ and ‘not likely’ for themselves.

For example,

• Comparing a woman who has a known risk-factor or condition to one who does not have said condition, would define “likelihood” by simple arithmetic. Statistically-speaking any pregnancy with a specific risk-factor is more likely be “affected” than the pregnancy without such factors, so “likely to affect” would be the default answer for the examining physician.
• Another possible interpretation for the word ‘likely’ is to apply it only to conditions that are ‘clinically-significant” and have diagnostic tests and medical treatments proven to substantially reduce the likelihood of a serious problem.
• The interpretation of ‘likely’ used in civil and administrative law is a metric of more likely than not likely to be causative 51% vs. 49% likelihood). This is the very important distinction between “possibility” and “probability” that is so central to the ‘right use’ of expensive and often scarce healthcare resources.

But under the language of AB 1308, each examining physician will have his or her personal interpretation of the language in AB 1308, so there is no way to predict if these terms are being applied appropriately.

However, AB 1308 states that:

“A licensed midwife shall not provide or continue to provide midwifery care to a woman with a risk factor that will significantly affect the course of pregnancy and childbirth, regardless of whether the woman has … refused care by a physician or surgeon, a licensed midwife shall not resume primary care of the client.”

The newly amended LMPA is very clear about what happens when the physician examiner designates the condition in question to be “likely to affect the pregnancy or childbirth”. As a class California LMs are are forever enjoined from providing care to that particular women during the current pregnancy, a decision that has no identified mechanism of appeal. The practical consequences is to promote unattended births or the re-invention of lay midwifery.

 Lack of appeal process or provisions for “Exceptional Circumstances” 

Licensed midwives are prohibited from providing care even if obstetrical consultation is geographically unavailable or unaffordable; for example, when there are no obstetrical providers within reasonable driving distance, the pregnant woman can’t get an appointment for 2 months, or their family can’t afford to pay the $500 to $1,500 consultant and ultrasound fees out-of-pocket, often the case for MediCal-eligible families. Unfortunately Medicaid/MediCal often denies reimburse for consultations and associated costs when not ordered by an MD, even when the exam itself is performed by an MD.

Other areas of serious concern not addressed in AB 1308 is the patient-rights issue of pregnant women with valid objections to being forced to involuntarily submit to unwanted obstetrical evaluations. This includes women from families that have a religious tradition of modesty that calls for female-only healthcare providers. Other cultural or religious traditions use healing practices that do not include allopathic medical care except in emergencies. Lacking an appropriate exception in the law, these families are forced into medicalized care without their consent or suffer the consequences of a denial of services.

The special situation of childbearing women with PTSD

Last but not least in this category are women with the great misfortune to suffer on-going symptoms of PTSD. This sometimes is the result of serious childhood injuries or illness that required them to be hospitalized for a long time while being exposed to frequent painful treatments. Other women may have PTSD symptoms from physical or sexual abuse as a child, rape or were traumatized during a previous hospital birth that involved unwanted or inadequate care, medical interventions or painful invasive procedures they did not consent to but were forced into by the situation.

For women with significant previous trauma that included the over-powering use of physical force or non-consensual sexual activity, repeated vaginal exams and other invasive procedures associated with the routine hospital management of labor frequently trigger flash-backs and disturbing memories.

Often women in this last category grimly state: “I just can’t go back to the scene of the crime. The only way I would voluntarily go to the hospital is if me or my baby are trouble.” Other women in this category are only able to find relative peace with their PTSD symptoms by scheduling an elective Cesarean section under general anesthesia.

It’s disturbing that a significant number of childbearing women should be facing such extraordinary problems.  Unfortunately for women who are unable to arrange a consultation or who decline obstetrical evaluation for any number of valid reasons, the only source of prenatal care and childbirth services available to them is the emergency room.

Patient-rights,  ACOG Committee Opinions 166 & 214; Wash DC 1910

ASIDE: Harpers ~ Dec. 2015 ~ The Bed Rest Hoax,

• (a) prolonged bedrest does not effective in prevent premature births
• (b) is harmful to the mother and associated w/ increased risk of pre-term birth

But contrary to science, approximately 700,000 pregnant women in American with ‘vulnerable pregnancies’ (usually signs of  PTL) are put on bedrest each year. As often the case, a physician’s order is assumed to be the definitive word on the issue, and takes on legal implications for anyone who declines an MD-recommended treatment or asks for a second opinion.

• hospital bed rest,
• medication to prolong her pregnancy, and
•  if necessary, forced delivery.

Using the LMPA in contradiction to its Legislative Intent

The legal purpose of the 1993 Licensed Midwifery Practice Act, as plainly stated in the legislative-intent section of the bill, was to expand access to maternity services in geographically underserved areas and make alternative maternity care providers and birth settings available to childbearing families who found the hospital-based obstetrical model to be expensive and unsatisfactory for healthy women with normal pregnancies.

For the last 50 years a substantial number of parents and couples planning to have a baby have expressed great dissatisfaction with the defensive practice of medicine and corporate interests of hospitals, which so often seem to take precedence over the personal and practical needs of their families.

These citizens were happy that such care was available to treat complications or in an emergency, but didn’t believe the routine medicalization of normal childbirth was safer, more cost-effective, or otherwise in their best interest. The LMPA was specifically configured to provide professionally-trained and state-regulated midwives to women who had no other alternative source of maternity care, and to create a safe alternative for families that would otherwise avoid unwanted hospital obstetrical care by having unattended or lay-attended labors and births.

Unfortunately the new restrictions added to the LMPA by AB 1308 have created a “denial of service” category for childbearing women with certain circumstances — those with certain risk-factors who cannot find, afford or arrange suitable obstetrical consultation, do not believe that such a consultation has any value to them and/or object on principle to being forced involuntarily into medical care that they are convinced is unneeded, inappropriate and exposes them to the unnecessary risks resulting from these medical and surgical procedures.

This is an economic as well as humanitarian problems. Lack of regular maternity care not only results in harm to some mother and babies, but these preventable complications are extremely expensive to treat. This added cost is passed on to taxpayers through the state-federal Medicaid-MediCal program. Approximately 50% childbearing families in our state qualify for these low income programs, which reimburse providers and hospitals for providing childbirth services.

If undetected or untreated, abnormal conditions and complications such as high blood pressure, diabetes, etc are likely to result in premature births and babies born with a serious illness. Without regular prenatal care, early detection is less likley, and substantially more pre-term and sick babies will spend weeks, sometimes many months, in the NICU at a minimum cost of $10,000 a day. The math for 90 days in the NICU is easy as it costs California businesses and taxpayers $900,000.

For the most premature and sickest of babies, the hospital bill is often over a million dollars. Since making maternity care MORE available was the stated purpose of the LMPA passed in 1993, its shocking to realize that California’s midwifery licensing law now include a provision to keep professional midwives from legally providing maternity care to women who have no other choices, or  logical reasons for not utilizing hospital-based obstetrics. Such a denial of services results in preventable harm for no good reason.

Acounting for the actual dangers of inadequate prenatal care & unattended birth

In 1984 a study was published in the American Journal of Obstetrics and Gynecology on maternal and perinatal mortality in an Indiana religious group that did not believe in the use of medical or midwifery care during pregnancy or childbirth, and also did not use medical services for mothers or babies following the birth, even when things were not going well. The study compared the overall rate of childbirth-related mortality in the state of Indiana for the early 1980s with members of the religious group that gave birth between 1975 and 1982. There were 344 women who had no or inadequate prenatal care and unattended births.

This study identified a 100 times higher rate of maternal mortality in women with no professional maternity care and unattended births; the main causes of mortality were the generally treatable complications of postpartum hemorrhage and infection. The number of maternal deaths was a shocking 1 out of 57, or 872 per 100,000 live births. In this no-prenatal care-unattended birth group, perineal deaths rate were 3 times higher, with 12 fetal and 9 newborn deaths out of 344 births or 1 death for every 16 pregnancies. The neonatal mortality rate was 45 per 1,000 live births (state NMR at the time was only 18 per 1,000).

Citation: Perinatal & maternal mortality in a religious group avoiding obstetrical care —> Am Journ Obst Gyne 1884 Dec 1; 150(7):826-31 Kunitz AM, Spence C. Danielson TS, Rocha RW, Grimes DA

Keeping childbirth safe in a 21^st century world

The basic purpose of maternity care is to promote, preserve and protect the health of already healthy women. What makes childbearing dangerous in the 21^st century is not having access (or failing to use) maternity care and comprehensive medical services when needed. The bitter reality is that no form of maternity care or obstetrical interventions can undo the damage of untreated chronic diseases in pregnancy, or childbirth in a women with a serious abnormality that could have been prevented by timely access to appropriate medical care.

The tragic outcomes reported in the ACOG study above is like an epidemic of kids drowning in a neighborhood pool because there are no trained lifeguards, being run over by cars on the way to school because no there are no crossing guards or planes colliding mid-air because we didn’t bother to put an effective aircraft control system into place. Swimming, going to school and flying in a plane don’t need to be life-threatening events. Like putting gas in the car before we take a trip, these activities are a relatively safe and enjoyable part of normal life when societies simply see that what is obviously needed to make then reasonably safe is supplied in timely manner.

Plain facts, hard truths

Five published sources were used to statistically determine the essential qualities of safe and cost-effective maternity care in the 21st century. These included four peer-viewed studies and a consensus of published literature reporting outcomes over the last decade for hospital-based maternity services in the US.  A comparison was made between the control group and each of the 3 categories of trained birth attendants.

These categories included:

(1) a control group of purposefully unattended births and the rejection of necessary emergent care in a contemporary population in the US (Indiana, pub. AJOG 1984)

(2) a retrospective study of experienced and state-regulated lay midwives who attended planned OOH birth for a low- and moderate-risk population of economically-disadvantaged women of color w/ spotty access to comprehensive medical service if able to pay out-of-pocket (North Carolina, pub. JAMA 1981)

(3) a prospective study of professionally-trained midwives who attended planned OOH birth in a low and modern-income population with reasonably good access to comprehensive medical services (US and Canada that included California licensed midwives, pub. BMJ 2005)

(4) a prospective Canadian study of professionally-trained and regulated direct-entry midwives, contrasting outcomes for a select groups of very low-risk women who gave birth under three specified circumstances (a) planned OOH birth under the care of direct-entry midwives, (b) hospital-based care by the very same category of direct-entry midwives and (c) and standard hospital-based obstetrical management by physicians

(5) a retrospective configuration of hospital-based obstetrical studies of medically-managed hospital births in low and moderate risk women by board-certified obstetricians, FP physicians and certified nurse-midwives.

Additional information on the ‘control’ group

Control group (1): The study reporting on unattended births functions as a control group that allows us to first compare outcomes of ‘care’ versus ‘no care’, and then compare the 3 major groups of state-regulated birth attendants to one another and the ‘no care’ cohort.

Taken together this provides vital information on the biological background rate of maternal and perinatal mortality and morbidity when all the benefits of modern biological sciences are absent, inaccessible or rejected by a childbearing population.

The reasons for this may be historical (living before scientific healthcare was developed) or due to inadequate efforts by governments (the failed-state syndrome or corrupt officials in countries with no infrastructure for modern healthcare).  In addition, there are individual barriers faced by each family, such as not understanding of the risks or importance of such services, geographical barriers, lack of infrastructure, inability to pay, cultural traditions and religious beliefs that are problematic.

The Really Bad News: The poor outcomes for purposefully unattended birth in the US in an educated (8th grade or beyond) and essentially healthy caucasian population are consistent with available statistics for maternal-infant mortality in in the US during the pre-antibiotic era of  the 18th, 19^th and early 20^th century, and the current high maternal mortality rates in developing countries such as Afghanistan, Ethiopia and the Gambia.

In these poor countries, laboring women often have to be carried for as long as 8 hours by stretcher to a passible road. After exhausted family members finally get to a regional hospital, they may find no doctor on duty, or no gas to run hospital generator, which is needed for operating lights so an emergency C-section can be performed in the middle of the night. Under such grim circumstances, a couple dollars worth of gasoline may make the difference between the death of the mother and her undelivered baby (making her older children into orphans), or a healthy new mother and baby that return to their family’s village to raise their children and enjoy a normal life.

The major cause of maternal death in this first-world cohort of women having unattended births were the same kind of preventable problems — postpartum hemorrhage and infection that killed women before the development of modern medical science, and is still killing women living in places without access to modern medical care — .

The good only thing to come from this tragic story is that it answers many of our question about the specific risks of childbirth in the context of our modern world. It does this by establishing a background rate of biological risk that is independent from poverty, malnutrition and other factors specific to deprivation. This in turn helps identify the core qualities of safe and cost-effective maternity care for the 21st century.

For a long time, the high MMR rate in third-world countries was blamed on poor diets, malnutrition and other economic factors. But WHO programs to feed childbearing women and provide other financial assistance didn’t do much to improve mortality rates.

That’s when it became clear that the critical element in childbirth safety was access to modern maternity care by formally trained and state-regulated midwives, in conjunction with a functional healthcare system. In places were trained midwives are able to screen pregnant women for abnormalities and complications, and refer them to comprehensive medical services as necessary, both MMR and perinatal deaths happily dropped from their previous stratosphere levels to a range comparable to and better than *some developed countries. {NTOE: the US currently ranks 60th in maternal mortality and 50th in neonatal deaths}

Brief comment on conventional obstetrics (5):

At the other end of the social and economic spectrum, statistical outcomes for obstetrical management as contrasted to other maternity care providers help to distinguish between obstetrical policies and practices that benefit healthy women, and costly, unproductive customs that do not directly contribute to improved maternal-infant outcomes.

Envelope Please . . .

People naturally assume that safe outcomes for hospital-base obstetrics would be miles out in front of their closest competitor, with CNMs following a respectable distance behind, then a long straggle of licensed midwives that finally drizzled down to lay midwives, who would rank a far distant 50^th place. But what everybody assumed to be self-evident turned out to be wrong.

The scientific literature in this review identified the single most critical factor in safe childbirth in the 21st century as access to maternity care within an effective and affordable healthcare system. In a race between “care” and “no care” (whatever the reason), the hands-down winner is regular prenatal care, medical referral as indicated, professionally-attended labors and births, followup services for new mothers and new babies and emergency transfer whenever  warranted.

Compared to the “no care” control group, an order-of-magnitude reduction in MMR was identified in ALL three categories of historical and contemporary birth attendants. This includes both state-regulated lay midwives and professionally-licensed direct-entry midwives. Excluding  congenital anomalies, differences in neonatal mortality rates between these three categories of maternity providers were not statistically significant.

Professional distinctions between physicians and midwives did not matter. What made an order-0f-magnitude in the relative safety of childbirth was that 100% of childbearing women received regular maternity care by trained birth attendants (physicians or midwives) within a functional healthcare system that was appropriately utilized as needed or if medical care was requested by the laboring woman.

The best outcomes for healthy mothers and babies are consistently associated a universal safety net that consists of three healthcare-related circumstances. This type of care is equally advantageous to women living in high-income industrialized countries as those who live in low-income developing countries:

(a) Regular prenatal care by midwife or physician that includes initial and on-going risk-screening, education in nutritional and healthy life-styles, psychological support and referral for medical evaluation or treatment as indicated

(b) Intrapartum care by a midwife or physician trained and experienced in physiological management who is physically present (or immediately available at the mother’s discretion) during all active states of labor, birth and immediate postpartum-neonatal period, and appropriate follow-up for new mother and new baby is provided or arranged for

(c) Access to and appropriate use of emergency services, hospital-based obstetrical care and other medical services if a complication develops or the mother requests medicalized care

Whether this kind of maternity care is provided by a midwife or physician, and irrespective of planned place-of-birth (hospital, home, or birth center), the essential elements of safe and cost-effective care for healthy mothers and babies are always the same — maternity care practitioners skilled in physiological childbirth practices who are trained and equipped to function in as an educated observer with emergency response capacity. The importance of role is similar to that of a lifeguard, school crossing guard or member of an air traffic control team.

What’s missing?

For the last hundred years, the big missing piece in the public debate is the often-ignored but well-documented fact that the inappropriate use of obstetrical interventions are just a much of a danger to mothers and babies as the underuse of needed interventions. Both ends of this spectrum are associated with unexpected, preventable complications and deaths. At one end are the heartbreaking risks of “too little, too late”. Those have already been discussed and their harm amply documented.

While the effects of overuse are not as familiar (or sexy) as ‘underuse, theses risks are every bit as real and consequential. For example, blood transfusions can be life-saving if you have a life-threatening illness or injury, but they have their own risks; occasionally there is some kind of a laboratory mix-up or a patient goes into anaphylactic shock and dies from allergy-provoking particles in the blood transfusion. Imagine how much worse it would be to take on 100% of the risk but get zero benefit, because you didn’t really need the medical treatment that now is threatening your life.

This principle of ‘overuse’ even applies to well-intentioned, well-conducted obstetrical management as routinely applied normal childbirth in healthy women. Complications of this type of medical care are rightly classified as “iatrogenic” — directly associated with medical decisions or medical services provided by or at the request of medical providers.

Testimony during a US Senate hearing in 2014 found that medical errors associated with hospital-based medical care are the third leading cause of death in the US. A study published in the Journal of Patient Safety concluded that as many as 440,000 people die each year unnecessarily from infections, preventable blood clots, adverse drug reactions, diagnostic errors, mechanical and procedural errors, inadequate staffing and unfortunate happenstance.

Dr. Ashish Jha of the Harvard School of Public Health noted that: “Our high spending is not buying us particularly safe care.”

Over-spending as well as over-treating is a particular concern in reaction to the current high MMR in the US, and not confuse the problem with the solution. Care must be taken that the public, press, or obstetrical professionals do not misinterpreted this as a call to throw more money at the problem by interventions. This kind of misunderstanding can easily lead people to believe that more medicalization, with an accelerating number of interventions used with greater frequency – that is, earlier and earlier in pregnancy or labor, with less and less actual medical indication — is the solution. But as Dr. Ashish Jha points out: “Our high spending is not buying us particularly safe care.”

One thing is absolutely sure: Healthy childbearing women in American are not suffering from a Cesarean section deficiency. In many developed countries, higher C-section rates track with higher maternal mortality.

What kept the US from developing a universal safety net like many other developed countries?

Problems with our current maternity care system began in 1910, when physicians concluded that being an MD also made one an authority on normal childbirth in healthy childbearing women. However, the principles and techniques of physiological management were not part of the medical school curriculum, and new graduates didn’t understand how to support normal biology or why they should bother. They had no appreciation of the greater safety and other benefits afforded by physiological methods, and also no respect for the dangers introduced by medical interference and surgical interventions.

Instead these early obstetrical profession related to the care of healthy childbearing women as a wonderful opportunity to develop their skills in interventive obstetrics. During this critical stage of the profession’s development every normal birth became an opportunity to use chloroform, episiotomy, forceps and manual removal of the placenta. By 1920, this had become the universal ‘standard of care’ in the US for normal childbirth, a model still in use when I retired from labor and delivery room nursing in 1975.

Unfortunately it was associated with unnecessary anesthetic deaths (3^rd place), PP hemorrhage (2^nd place) and infection (1^st place) and long-term gynecological complications following forceps deliveries. The news was not good for newborns either, as the regular use of narcotics, anesthesia and forceps greatly increase the rate of respiratory depression and birth injuries that included death or permanent neurological disabilities.

Luckily the most egregious of those unfortunate practices are long-gone, but many older problems were simply replaced by newer or more technological versions of medical and surgical interventions. As before, these interventions were originally developed to treat serious complications, but (as before) are being used preemptively, prophylactically on healthy women; in spite of everyone’s best intentions, iatrogenic complications and increased preventable mortality of both mothers and babies are all too frequent.

A 100% access, 100% of the time

The core issue for 21^st century maternity care is creating a system that is accessible, affordable and acceptable to 100% of childbearing women. These new mothers should be so satisfied and excited about their prenatal care that they want to come back with their babies for follow-up care during the postpartum-neonatal period. That is real health care, where it really counts.

If the governments, health insurers or public-interest groups want to reverse the current epidemic of type II diabetes in children and young adults, they should harness the power of midwives teaching the principles of healthy nutrition as part of prenatal care. These pregnant women then return home to spread the word inter-generationally to their husband, older children, parents, siblings, grandparents, nieces, nephews, friends, and next-door neighbors, eventually seeding this important information through the community. That is what ‘health care’ looks like – caring people working together to create health life-styles.

21^st Century Maternity Care for 70-plus percent of health women

Mastery in normal childbirth services for healthy women means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. For an essentially healthy population, the most appropriate and cost-effective model of maternity care provides maximal results with minimal interventions.

This means seeking out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest interventions and least expense to the health care system.

In such an evidence-based model, the individual management of pregnancy and childbirth would be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the careprovider (obstetrician, other physician, or midwife).

This means integrating the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for healthy women with normal pregnancies, while reserving obstetrical interventions for those with complications, or if requested by the mother. The resulting ‘best practices’ would then apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.

For that to happen, maternity care providers and childbearing must not be burdened with unnecessary limitations and illogical regulations that result in an irrational denial of services to certain groups. The smart money is on cost- effective, life-preserving maternity care for 100% of childbearing families, 100% of the time.

Please click here to read an addendum compiled for our Amicus Brief.

It’s titled “Historical and Contemporary comments about by physicians about midwives  ~ 1820 to 2014“

Moved to a stand-alone post

Mandatory Physician Supervision &
Mandatory Physician Referral: 
Two sides of the same coin

The name of that ‘coin’ is “borrowed servant/captain-of-the-ship”. This legal theory describes the relationship between medical doctors whose role is defined as the “Captain of the ship”, while nurses (or other ‘assistants’) are defined as the doctor’s “borrowed servant“.

Legal scholars typically refer to this as a construct to hold doctors with hospital practice privileges (i.e. independent contractors) responsible for the actions of subservient hospital employees who were under the doctor’s authority and/or supervision. In event of malpractice suit, the physician will also be responsible for any monetary damages even if the harm was the result of an error made by the nurse of other assistant.

However,  “borrowed servant-Captain of the Ship” perfectly reflects the social strata and power dynamics that the medical profession created and expects to enjoy and benefit from in regard to nurses, nurse-midwives and licensed midwives and other “underlings”. This is plainly laid out in California’s 1974 CNM licensing law and the 1993 LMPA and in the mandatory physician referral in AB 1308 in 2013.

Notice how all “roads lead (back) to Rome” in that all control and decision-making, as well as disportionately profit from the labor of others always comes back to MDs at the top of the food chain.

Here are three historical quotes from obstetricians in 1922 that plainly identifies the intended relationship between doctors and their subservients, that is, ‘borrowed servants”:

“The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions; he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee. This means … the doctors must be relieved of all work that can be done by others —… nurses, social workers, and midwives.” [1922-A; ZieglerMD, p. 412]

“The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants when things go wrong; and the midwives should be trained to do the work of the so called “practical nurses,” acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant- attendants upon women in labor—conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery.” [1922-A; ZieglerMD]

“In this plan the work of the doctors would be limited to the delivery of patients to consultants with the nurses, and to the making of complete physical and obstetrical examinations …  [1922-A; ZieglerMD, p. 413]

In this system MDs make all the decisions about what is to be done — drugs administered, whether the patient is ‘allowed’ out of bed, what he or she is allowed to do or eat. Doctors convey this to the nursing staff via “Doctors Orders” and various “standing orders” that outline what nurses can do without having to call the doctor first to get an “order”.

The original supervision provision in California’s nurse-mfry law mirrored the same hierarchical system that has always defined the status and power arrangement between doctors and nurses.

However, a great many CNMs become “independent contractors” instead of employees so they had to be put in their ‘appropriately ‘ subservient place in the medical hierarchy by only being allow to work under the thump a supervising obstetrician.

This was achieved by mandating a written “practice agreement” in which the supervising obstetrician defines what the CNM  and can’t do, who she can provide care to and outlining the circumstances in which she must “call the doctor” to get permission to provide or continue to provide care, or be told (“doctor’s orders”) that she must refer or transfer care to her obstetrical supervisor or the hospital, even when the mother did not consent (i.e. 42 wks w/ normal AFI and reassuring fetal heart rate).

AB 1308 achieved many of the same goals as the 1974 CNM law by negating the inherent independence in the LMPA as written by Senator Lucy Killea. This put the profession of licensed midwifery under the medical profession’s hierarchal system in the same subservient status as nurses and CNMs.

AB 1308 took control away from mothers by eliminating their right to informed consent and refusal. It structurally eliminated the professional status of licensed midwifery by canablizing the LMPA’s scope of practice, eliminating our standard of care and substituting a list of what LMs can’t do. This statutorily eliminated the midwife’s independent decision-making process that traditionally included the decision to consult with MDs when a client’s situation or health status required additional information or referral.

Ultimately, AB 1308 gave the obstetrical profession a statutory tool that recreated the social strata and power dynamics in which the physician is legally identified as “captain of the ship” who “gives the orders” and midwives (CNMs or LMs) are the “borrowed servants”.