Catching

After catching a baby for the first time in my apprenticeship I am even more committed to encouraging parents to catch their own. There's something so special and so amazing about having your hands on a baby as it is born and I felt a much deeper attachment to the baby than I have at births where I just observed. Those amazing feelings belong to the parents! That connection and energy I received would have been better placed with the mom, dad, grandma, aunt - someone more intimately and long-term involved with the child.

My number one goal as a midwife is to find and eliminate the ways in which I might inadvertently take what is not mine to take. Birth energy is strong. Gratitude from parents is a big warm fuzzy. Catching a baby is amazing. Our society promotes a birth attendant as necessary for safety. It's no wonder that some midwives fall into the trap of self-importance; viewing themselves as an authority in the situation. But everything about the birth belongs to the parents. The energy, the oxytocin pheromones, the news, the announcement, the details, the story, the accomplishment, the grief, the joy, the pain, the baby, the first moments of parenthood; all belong to them. Midwifery is above all service work. If you want to be a director, go to Hollywood.

What is medical?

One of the arguments against regulating midwifery in the same way that medical practitioners are regulated is that midwifery is not the practice of medicine. The argument is that since pregnancy is not a medical state, how can the support, the being "with" the pregnant women, be the practice of medicine. The argument goes further for some people that midwives should not receive medical insurance payments for a non-medical service. This is a profound argument for me. It speaks to my heart and feels so true. To use a tired analogy, it is very much like bowel movements. In general they are not a medical event. They are a bodily function. Sometimes there is a variation of normal such as diarrhea or constipation. These situations carry higher risk, but are ultimately still normal. Occasionally there may be a complication such as an obstruction that raises this bodily function (or the body's inability to complete it on its own) to a medical problem. So too with birth. Generally it's a bodily function, variations of normal occur such as breech, twins, or funky positioning that may carry higher risk but are ultimately normal and occasionally a complication will occur that requires medical intervention for the birth to complete itself. Therefore, normal birth is not medical and complicated birth is.

But here's the rub. Modern midwives tend to do things like draw blood or request the report from someone else drawing blood, carry oxygen, carry pharmaceutical means of stopping hemorrhage, identify and sometimes diagnose complications, administer injections and use high-tech equipment to monitor the body.

What is medical? Is the intimate understanding of the inner workings of the pregnant woman and baby medical knowledge? Is the reading of blood labs to monitor health a medical action? Is assisting a woman with the variations of normal that increase her risk medical intervention? Is diagnosing the complication and recommending transfer to a medical facility practicing medicine?

Where do we draw the line between the wise-woman support of being a knowledgeable presence at a normal birth to facilitate the woman's own ability, and the next level of care which involves the diagnosing and in many cases resolution of variations that require assistance and complications which require a more forceful level of intervention?

Tabors defines medicine as "1. A drug or remedy. 2. The act of maintenance of health, and prevention and treatment of disease and illness. 3. Treatment of disease by medical, as distinguished from surgical, treatment. (emphasis mine, Tabors 18th Ed. p. 1175)

The Oregon law describes the practice of a licensed midwife as providing health care, support and information to women during pregnancy, birth and the post-partum period as well as to the baby. This includes the "Identification of, implications of and appropriate treatment for various infections, disease conditions and other problems, which may affect pregnancy." and furthermore defines the "Emergency skills of midwifery" as "the provision of vital sign assessment, CPR, infant resuscitation, maternal hemorrhage control, charting, fetal monitoring, treatment of shock, essentials of maternal and infant transport procedures, and the setup of necessary equipment." (OAR 332-015-0000, 332-015-0040)

Even midwives who have not chosen to be licensed help the woman maintain her health and may give her a remedy for her body and may provide treatment for her ills. It becomes clear that midwifery could indeed fall under the definition of practicing medicine. Technically everything we do to maintain our health is connected to that definition of medicine and the ways that I treat my children when they are sick is the practice of medicine. But that takes me back to pregnancy and birth being normal bodily functions. Maybe instead of saying that birth is not a medical event, we should say that birth is not a pathological event. In any case this debate has certainly been ongoing for a long time. In a 1904 article in the California State Journal of Medicine, a self-styled osteopath who had apparently been accused of practicing medicine without a license was quoted as saying "to deny the right to the free an untrammeled use of one's hands upon the body of a sufferer, for his benefit, at his request is to deny constitutional right." (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1649684/?page=1)

Certainly during the prenatal period it could be said that midwives are simply consultants. The actions of the mother in her own life are the things which maintain her health. But during birth and post-partum, the likelihood that the midwife will stray into assisting in that process of maintaining health is greater. A midwife sitting on her hands and simply "being there" during a normal birth is providing the best of care. A midwife who assists the woman through positional changes and physical support of the body in order to resolve variations of normal that may be dealt with at home through intervention and otherwise would lead to a hospital transfer, now that is the sticky part if you are clinging to the definition.

What do you think? Is midwifery the practice of medicine according to Tabors? Should midwives accept health insurance for a non-pathological event? What is the justification for non-regulation of midwifery when every other health-care practitioner is regulated? Can we come up with a concise and logical argument?

military women

At the Trust Birth conference I was deeply moved and terribly saddened to listen to the account of active-duty military women who have no choices in maternity care. I listened to the pain of one woman who, facing criminal charges of disobedience of a direct order, was forced to consent to a cesarean section for no other reason but that her previous child had been born via surgery and the care-provider that had promised her a vbac trial left the hospital 2 weeks before her due date. She spoke in the choked and strangled voice of a rape victim and described her childs "birth" as a sexual violation.

a change of focus

I've been reconsidering licensure for a while now but hadn't been able to form my feelings into concrete enough thoughts to take a stand. After hearing some amazing women who have been midwives for a long time talking about licensure and certification and how it affects midwives and especially mothers I have decided against seeking certification with NARM or licensure in my state.

I encourage everyone to think critically about licensure and the push to license and certify midwives across the US. I don't believe that it will ensure midwifery care availability to all, I think over time it will end up restricting OOH care for the women who need it most. The state should not be the one who decides who can attend a woman's birth, nor other midwives, licensing boards, other parents or professional organizations. Each woman should be free to choose anyone or no one to be with her as she births (which is, after all, a normal bodily function and not a medical event). The fight for birth choices should not be about midwifery but about mothers. After all, when mothers lose the right to choose (anyone or no one) the rights of midwives are moot.

Due dates

I picked up a book at a used book library sale the other day. It's called Eastman's Expectant Motherhood and it's a very medically focused consumer oriented pregnancy book. The first publishing was in 1940 but this edition was published in 1977. It's a wonderful little time-capsule of obstetric thinking not so very long ago. Here's what it has to say about due dates:

"The length of "term" pregnancy varies greatly; it may range, indeed, between such wide extremes as 240 days and 300 days, and yet be entirely normal in every respect. The average duration, counting from the time of conception, is nine and a half lunar months; that is thirty-eight weeks (266 days). Counting from the first day of the last menstrual period its average length is ten lunar months (forty weeks; 280 days). That these average figures mean very little, however, is shown by the following facts. Scarcely one pregnancy in ten terminates exactly 280 days after the beginning of the last period. Less than one half terminate within one week of this 280th day. In 10 percent of cases birth occurs a week or more before the theoretical end of pregnancy, and in another 10 percent it takes place more than two weeks later than we would expect from the average figures cited above. Indeed, it would appear that for full development some children require a longer time in the uterus, others a shorter time.

In view of the wide variation in the length of pregnancy, it is obviously impossible to predict the expected day of confinement with any degree of precision. The time-honored method, based on the above average figures, is simple. Count back three calendar months from the first day of the last menstrual period and add seven days.... While it may be satisfying to the curiosity to have this date in mind, it must be understood that the likelihood of labor's occurring even within a week of this day is less than 50 percent. There is one chance in ten that it will come at least two weeks later.

And yet, whether pregnancy terminates a week before or two weeks later than the day calculated, the outlook for mother and child is usually just as good as if it had ended at high noon on the due date. Actually, women seldom go "over-term"; in most of these cases it is the above system of calculation and not nature which has erred. For example, ovulation and hence conception may have occurred some days later than usual; this would throw both beginning and the end of pregnancy just that many days later. if, superimposed on this circumstance, we were dealing with a child who required a slightly longer stay in the uterus for complete development, it would be clear that the apparent delay was quite normal and for the best."