Open Letter to the ACNM Board of Directors and Executive Director

Think together, no.

Pull together, yes.

-Michelle Ellsworth

TO: Open Letter to the ACNM Board of Directors and Executive Director

FROM: Geradine Simkins, CNM, MSN, MANA Board President

RE: ACNM Opposition to Federal Recognition for the CPM

DATE: July 16, 2009

I am a CNM and a member of the ACNM and I say very emphatically—not in my name! I do not support your recent decision to publicly and aggressively oppose the efforts of a broad-based coalition of six national midwifery and consumer organizations to seek federal recognition of the Certified Professional midwife. Your position, to me, is indefensible.

Lack of Evidence

For an organization of professionals that values evidence, we find it inexcusable that you have chosen an action that the evidence does not support.

• There is not evidence to support your claim that the majority of CPMs are not properly qualified to practice.
• There is no evidence to support the position that CPMs in general have poorer outcomes than CNMs or CMs.
• There is no evidence to support the position that CPMs trained though apprenticeship and evaluated for certification through he Portfolio Evaluation Process (PEP) of NARM have different outcomes than CPMs trained in MEAC-accredited schools.
• And there is no evidence to support the notion that a midwife with a Master’s Degree has better outcomes than one without that level of higher education.

The evidence we do have on the CPM credential indicates that the midwives holding this credential are performing well, have good outcomes, and are saving money in maternity care costs. The growing number of women choosing CPMs suggests that women value the care provided by CPMs. If research in the future demonstrates that the PEP process is not safe or is not cost-effective, then that is the time to reassess and restructure the process.

Differing Values

We, as midwives, have values that underpin our professional practice. We cherish and honor those values. You have stated that your board made its decision because ACNM strongly values formal standardized education, and opposes federal recognition of CPMs who have not gone through an accredited program. We can accept that you strongly value standardized education. However, we strongly value multiple routes of midwifery education for a variety of reasons.

There is something important, powerful and valuable in a training process in which the student midwife or apprentice is educated in a one-on-one relationship with a preceptor and her clients in the community, as opposed to the tertiary setting where student midwives don’t follow women throughout the childbearing year, and may never experience continuity of care or individualized care. In addition, by preserving multiple routes we are able to educate more midwives, not fewer. We need more midwives! If health care reform were to turn around and adopt the midwifery model of care as the gold standard this year, we could not possible supply “a midwife for every mother”.

Impact of Taking a Stand

By publicly and actively opposing federal recognition of CPMs as Medicaid providers, in addition to taking a stand about formal education, you are also taking a stand (willingly or inadvertently) for decreased access to midwifery care, diminished choice for women to chose maternity care providers and place of birth, and restricted access to the profession by potential candidates. Is it worth it to sacrifice several things that you value, just so that you can take a stand for one thing that you value? Is it possible for you as an organization to value something, but also realize that it is not the only valid way? Is it possible for you to respect the diversity of pathways to midwifery that the CPM represents? It does not require the ACNM to sacrifice its own standards. It simply requires the ACNM to respect the standards of another part of the profession of midwifery.

Disingenuous Claims

It is disingenuous of ACNM to state in its Special Alert to ACNM Members on July 15, 2009, “ACNM’s decision to oppose this initiative followed unsuccessful attempts by ACNM and MAMA Campaign leaders to reach a compromise that both organizations could support…” There was no formal process or interaction, no back and forth negotiations, no attempt at collaboration that occurred between ACNM leaders and MAMA Campaign leaders. There was one phone conversation in which the ACNM representative stated that there was only one compromise that they would accept: federal recognition only for gradates of MEAC-accredited programs. While there are multiple educational paths to achieve it, the CPM credential embodies a single standard body of knowledge and experience. It cannot be split into parts. Therefore, the MAMA Campaignis promoting all CPMs to receive federal recognition as Medicaid providers, not some CPMs. There is no room for compromise when one side gets everything they want and the other side does not get what they want at all.

It is also disingenuous to suggest the World Health Organization (WHO) document sets a standard that has been embraced around the world. In fact, the WHO developed global standards for midwifery education without the input of the International Confederation of Midwives (ICM), an international partner of the WHO. The majority of members of the task force that developed the standards were not midwives. There was not widespread input regarding the document. In response to this oversight, the ICM passed a resolution at the June 2008 Council meeting in Glasgow Scotland (I was there!) to develop global midwifery standards. A task force has since been convened and all member organizations (which includes MANA and ACNM) will be able to give input to the standards developed by the ICM. Generally, when the ICM develops a document that might supplant an existing WHO document (as was the case in the international definition of a midwife), the ICM document is eventually incorporated by the larger international community. This will be a long process and any new document will not be ratified by ICM until the next Council meeting in 2011.

Lack of Vision

What offends me as a CNM, an ACNM member, a member of the MANA/ACNM Liaison Committee, and the President of the Midwives Alliance is the lack of vision that your decision represents.

Why not embraces diversity and support innovation? Why not bring the turf wars to an end? Why not unite under the banner of midwifery and the values that we share in common? Why not set aside our differences and recognize that we are all midwives? Why not recognize that the work we do is more important than the credentials we hold? Why not support one another within the profession, because diversity is our strength not our weakness?

What We Do Matters

The healthcare debate has been in progress in Washington DC for over a decade. But never before has the possibility of real change been so promising as it is now. Now is the time when we may have a real opportunity to impact changes in maternal and child health care that will have long-lasting affects for mothers, infants, families and communities. Women deserve high quality maternity care, affordable care, and equal access to care. Women deserve a variety of maternity care choices in providers and place of birth. Vulnerable and underserved women deserve to have disparities in health care outcomes eliminated, and they deserve to have barriers removed that limit services, providers and reimbursement for maternity care.

Expanding the pool of qualified Medicaid providers to include CPMs will help address the plight of so many women around the county who receive poor quality maternity care or do not have access to care at all. We need to lower the C-section rate and increase VBACs. We need to lower infant and maternal mortality and morbidity rates in the US. We need to offer women the opportunity to believe in their bodies again and to give birth powerfully and in their own time. We need to welcome babies gently into the world. We need to give the experiences of pregnancy and birth back to families. We need to support women to breastfeed and help shelter the process of maternal-infant bonding. These are the real issues. These are the things we deeply value. Midwives are the solution that can address each of these vital issues. For all midwives and midwifery organizations to be united under this banner is what is really important, not a continuation of turf-war battles that distract us from reaching our common goals. We do not have to think together; but we must pull together!

In Conclusion

I repeat to you—not in my name. As an ACNM member, your actions this week do not represent what I value, what I hope for, and what I work untold hours to achieve, nor do your actions represent what my Board of Directors values. I have written this letter at the urging of my Board of Directors. There are 14 members of the MANA Board —seven CPMs, four CNMs, one CPM/CNM, one CM and one DEM; truly a cross-section of the midwives that practice in this nation. What we stand for is diversity, tolerance and unity among midwives and within the profession of midwifery. What we advocate and work for is a midwife for every mother, in every village, city, tribe and community in the country and across the globe.

Sincerely,

Geradine Simkins CNM, MSN, President

MANA Board of Directors

Maria Iorillo CPM, 1^st Vice President

Christy Tashjian CPM, 2^nd Vice President

Angy Nixon CNM, Secretary

Audra Phillips CPM, Treasurer

Pam DyerStewart CPM, Region 1

Regina Willette CM, Region 2

Tamara Taitt DEM, Region 3

Sherry DeVries CPM, CNM Region 4

Elizabeth Moore, CPM, Region 5

Colleen Donavan-Bateson CNM, Region 6

Dinah Waranch CNM, Region 9

Cristina Alonso Midwife, Region 10 Mexico

Michelle Peixnho CPM, Midwives of Color Section

Where there is No Neonatologist

Q: What is a Neonatology?

A: Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn infant. It is a hospital-based specialty, and is usually practiced in neonatal intensive care units (NICUs). The principal patients of neonatologists are newborn infants who are ill or requiring special medical care due to prematurity, low birth weight,intrauterine growth retardation, congenital malformations (birth defects), sepsis, or birth asphyxias. (Wikipedia)

Q: What does a Neonatologist do in a hospital?

A: Supervises and works in the Neonatal Intensive Care Unit making decisions about unwell and premature infacts.

Q: How many neonatologists are there at the Regional hospital that attends to San Cristobal and the Highlands of Chiapas?

A: One

Q: And how many shifts are there?

A: 5. Morning, afternoon, night. Weekend day and weekend night.

Q: And when does the Neonatologist work?

A: Morning shift from monday to friday

Q: When do most births occur?

A: At night and on weekends

Q: So, who monitors the Neonatal Intensive Care Unit at the Hospital on weekends?

A: A Pediatrician

Q: Is a pediatrician qualified to manage an NICU and make decision regarding neonates in intensive care?

A: Not unless he or she has done specific certified training on this issue

Q: So basically you are saying that aside from mornings from mondays to fridays the NICU is not run by qualified staff?

A: Exactly

Q: At what consequences does that bring?

A: That over the weekend babies die that should not die because they are not intubated, ventilated or recieve appropriate treatment.

Q: And what is being done about this?

A: For the moment, nothing.

Q: So babies are dying over the weekend at the Regional Hospital because there is no qualified personel. Is there another hospital that has an NICU in the area?

A: No, the nearest one is the pediatric hospital in Tuxtla Gutierrez.

Q: So what would your advice be?

A: I would suggest that babies born on weekends make sure that they are at term, suffer no asphyxia, do not aspirate meconium or amniotic fluid, do not have any congenital anomalies because they have a very low probability of making to to monday.

Q: Thank you.

Intimacy

This week in Family Circle we talked about intimacy. The family's had asked to talk about sex, but I thought before talking about sex life after the baby, perhaps we should talk about intimacy first. We sometimes give sex and our sex life a lot of weight and consider that either we have a sex life or we don't. That if we have sex, we have intimacy as a couple and if we don't we don't. And this is a measurement of our relationship.

What we challenged the families is to think of Areas of Intimacy, as gradients, or degrees, instead of an all or nothing. As a couple we can look into these areas of intimacy and think about how we are doing within them. Perhaps we will find that one area is really strong and another is really weak. Then what we can do is put more effort into re-inforceing certain areas.

Consider these areas of intimacy:

As Parents: How we make decisions as parents (not the time we spend with our kids, but as a couple talking about how we parent)

Spiritual: We may share a religion, or a sacred process or thought or ritualize certain events or moments

Recreational: How we share having fun, what we like to do together

Asthetic: Our appreciation of what is beautiful to us

Crisis: Walking together through crisis, either an external crisis where we lean on the other or an internal relationship crisis where we are pulled together by our effort to reconcile and heal

Emotional: How we share, live and communicate our emotions

Sexual: How our sex life is lived, discussed and felt

When we consider intimacy by areas we can assess our balance or imbalance on a qualitative scale. We can work on enforcing certain areas and we will find that the better our intimacy gets in one area, the better it gets in another area. For example, if we agree that on saturday mornings we will bike ride together because we enjoy doing that, we will probably find that on saturday nights our sex gets better!

What we discussed in Family Circle (the first tuesday of every month at Luna Maya) was that during pregnancy couples can work on improving specific areas of intimacy so that when baby comes we can communicate our needs for intimacy as a couple, separate from the all consuming parenting.

If a couple has already had a baby and the couple feels astranged, perhaps they can check out these areas and see where there is possibility for improvement. Sometimes, its ok to pump milk, leave baby with grandma for a saturday morning so that mom and dad can have a bike ride and share some intimate time together.

It is important to remember that the new baby lives with two (sometimes) adults, and these two have a relationship that will immediately affect the baby. Lets give ourselves time as a couple to work on our areas of intimacy. We will teach our kids the importance of this and foster intimacy and communication among our newborns.

When you leave before it was expected

Dear Baby,

For some mysterious reason you chose me to be at your birth. And you chose me to be at your death.

For some mysterious reason your mother and father chose me to be at your birth. And they chose me to be at your death.

For some mysterious reason I chose to be at your birth. And I chose to be at your death.

Dear baby, who am I to judge whether a shorter life is worth any less than a longer life?

Who am I to decide that the minutes, hours, days, you spent on our earth were too little? They were enough, for you, they were enough.

For some mysterious reason, your short time with us was all that you needed.

I honor your life and I bow before you, honoring your destiny.

I place you in my heart and I bring you into my life, through your life, through your death.

I honor your life, as short as it was.

I honor your destiny.

(To those who left before their time, to the mothers and fathers who watched them and to the midwives who held witness)

Vaginal Breech Birth

The Society of Obstetricians and Gynecologists of Canada recently revised their practice guidelines on breech birth.
As of this week (June 2009) They no longer recommend routine cesarean for breech babies! This is a huge step forward as it was precisely the Canadian society and research from Canada that originally published and pushed material that deemed vaginal breech birth unsafe.

The announcement from the SOGC is here:

http://www.sogc.org/media/advisories-20090617a_e.asp

The guidelines:

http://www.sogc.org/media/pdf/advisories/CpgBreechJune09_e.pdf

At Luna Maya we have always supported women's right to chose the birth that she feels works best for her. This sometimes has included a breech vaginal birth. For any midwife who has attended home breech births, we know that it is safe, gentle and usually pretty straightforward.

One of the most important statements in my mind of the announcement and guidelines is the acknowledgement that there are very few providers (in hospital) who know how to attend a safe breech vaginal birth. I would like to offer the skills of myself and other homebirth midwives who how centuries have been safely attending breech births at home.

May this be the beginning of the extension of equal opportunity for birth and the extension of rights to ALL childbearing women, regardless of the position the baby is in!

Risks of Cesarean

Please check out this Blog entry regarding cesareans:

http://mannursediaries.blogspot.com/2009/05/nearly-bleeding-to-death-from-cesarean.html

I would love to read your comments on the story.

Notes on Prematurity

Midwives have very little experience with preterm labor, not so much because we are supposed to refer it, but because it rarely happens with women in midwifery care. This has to do with 1 hour prenatals that focus on emotional support, nutritional advice and holistic care. So my first note regarding prematurity would be that every woman get a midwife. Even if she ends up with a medicalized birth and a baby in intensive care she would probably benefit on someone to guard the normal- go to her house every day and listen to her, hold her, help her figure out why her baby is feeling like she needs to get out of her mothers safe womb. A midwife can help be an advocate if they end up in a pre term birth, helping the woman keep up some sort of milk production, advocating for kangaroo care and skin to skin contact which have been proven to improve outcomes for premmies. And long term support as well. Moms often talk about how estranged they feel from their baby who spent her first few weeks in the Neonatal Intensive Care Unit with a team of experts and all of a sudden mom is home with this fragile stranger. Its hard!!!

Last year I heard a midwife who works with a group of women who have really high rates of premature birth. She talked a lot about the "toxic womb", a place so stressful and malnourished that babies have to leave them before their time. She talked about 2 important aspects- stress... what are we passing to our babies- what messages, what hormones, what thoughts.... what is the burden of continuing the pregnancy for another 2 months on the mother- exhaustion, financial drama, career stuff, on and on. Each woman needs to define deeply why it is best for her to have her child out sooner than what should be. These questions are hard and challenging, but when women identify their responsibility in that and talk to their baby and understand that finally baby in or out, those stressors are still there.

Then nutrition- its very hard to improve nutrition in adults and in women at the end of their pregnancy, however right now baby needs a lot of nourishment. Omegas, protein, liquid, etc... she must eat and eat and eat. But she needs to eat from the Earth. 

I just finished reading a book about nourishment and moms and babies (Laura Gutman, La Revolucion de las Madres, 2008). The thesis of the book is that nourishment is our relationship to being loved and giving love. The womb is the epitome of nourishment, 24 hours a day of food and love and warmth. Why would anyone want to leave that?? This author talked out premmies as starting their life immersed in high technology- their existence depending on that. She works with women to help them grasp that their bodies are sublime technology and irreplaceable. All the tubes in the world will never replace the placenta!

At Luna Maya when we have had moms in this position we recommend bed rest, nutrition and hydration and the midwives and family therapist visit her at home to clarify what is going on. Recently a woman in her 33rd week of pregnancy called to say she thought she was going into labor. I gave her Aconite (homeopathic) for her fear. Her issue was that during her pregnancy she had come to realize that her boyfriend not available to her and her pregnancy and she couldn’t count on him for fathering her child and supporting her. So she had decided to say goodbye to him.

We talked about the difference between expelling her man from her life and expelling her child from her womb. Everyone has their place in the family and that needs to be honored. Within 24 hours of intensive midwifery care and some support from the therapist she was a whole different woman with a quiet uterus. She finished the week thanking us for how safe and comfortable she feels with us. I finished the week thanking her for opening her heart so gently and taking such good care of herself and her baby.

There is a reason why we shouldn’t be born before 36 weeks and every mother facing a premature birth needs to connect deeply with that. The mother, more than her doctor or midwife needs to know that she will carry this baby to term and take her baby back to the family bed hours after birth where she belongs for delicious honey momma nourishment. And we, as those who hold moms need to provide mom with delicious honey momma nourishment. Moms who nourish their little ones need to be nourished by the rest of us. Prematurity is our responsibility.