ACOG year in review statement 2007

Last night my friend Laura Shanley came over and we spent hours pouring over this little gem from the American College of Obstetricians and Gynecologists. We were smoking cigars and plotting and planning how to respond to this diatribe against homebirth…. After 7 hours of non-stop focused back and forth on how to prepare for this blog entry, I finally decided to just lay it on the line. Disbelief, sarcasm, and humor…the only way to deal with the Dinos from the Medical Establishment.
Actually Laura spent about four seconds forwarding me this little ditty and I spent about three minutes writing her back and writing my responses to the statement just took a little over 20 mintues. Don’t you just love the web??? Blogging, Email, and Links…a birth activists best friend.
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Jenny Hatch
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My responses to the ACOG 2007 Review are BOLDED and in ITALICS.
‘Lay’ Midwives & Home Birth
Troubling Trends in State Legislation:

■ Home birth bills on the rise.
■ Least qualified direct-entry midwives gaining licensure.
■ The midwives’ advantage.
■ ACOG on the defensive.
Home Birth Bills on the Rise
We are seeing an increase in ‘lay’ midwifery bills in the states. Backed by individual
State Midwifery Guilds and by the Midwives Alliance of North America (MANA) and its
credentialing unit, the North American Registry of Midwives (NARM), these bills are
being introduced – and passed – in more and more states.
For example, in Virginia in 2005, certified professional midwives (CPMs) finally
prevailed in what had been a decade-long campaign for licensure and legalization of
home birth. New Republican majorities in the Virginia General Assembly helped assure
the midwives’ victory. This year, it was the Missouri midwives who prevailed in their
perennial battle for licensure.
(A lawsuit has been filed to block the new Missouri law.)
We just can’t lose the one state in the union that has the most “Progressive” (bass ack ward) legislation on homebirth and was going to be our model for the rest of the country!!!
What’s behind this trend?
A legislative handbook developed by MANA provides insight into the midwives’
strategy. The 96-page handbook is full of lobbying advice, tactics and propaganda. It
includes a detailed step-by-step primer on getting a home birth bill passed.
The American Legislative Exchange Council (ALEC), an influential 2,400 member
organization of conservative state lawmakers, recently endorsed a model bill for the
licensure of certified professional midwives (CPMs) which was crafted by
MANA/NARM. Model legislation developed by ALEC gets wide attention in state
legislatures across the country.
The ‘lay’ midwives’ internal philosophy on state regulation and licensure appears to have
shifted. In the past, their position on licensure reflected the dominance of midwives who
did not want to be regulated, opposed state licensure, and defended within their
individual guilds the right to stay unlicensed and practice underground. While there are
midwives who still do not want to be regulated and who do not support the current
licensure campaign, for the most part you don’t see them speaking publicly against
licensure in the legislature or elsewhere. Even the nurse-midwives no longer can be
counted on to speak publicly against home birth or lesser trained midwives.


Least Qualified Direct-Entry Midwives Gaining Licensure
Next thing you’ll know they will make it legal for FATHERS to deliver their own children…as if a bunch of loser Dads could ever learn the basics of home childbirth….the nerve of these people!!!
􀂃 More states are adopting the CPM credential for midwife licensure, not CM.
􀂃 Only New York has one unified framework for licensing all midwives.
􀂃 ACOG does not support midwives who are not certified by ACNM.
The term direct-entry is used to refer to midwives who enter the profession of midwifery
directly without earning a nursing degree. Both certified professional midwives (CPMs)
and certified midwives (CMs) are considered direct-entry midwives, although their level
of education and training varies markedly.
CPMs are largely self-taught and their training is typically through apprenticeship. CPM
was the title chosen by MANA and NARM in the mid-1990s for their credentialed directentry
midwives.
By comparison, CMs must undergo three years of university-affiliated training, and while
there is no nursing prerequisite, these direct-entry midwives must complete the same
science requirements and sit for the same certification exam as a nurse-midwife. (See,
ACOG Statement of Policy, Midwifery Education and Certification, February 2007)
New York is one of the few states that recognizes the CM credential and requires all
midwives to meet this minimum level of education and training. New York has one
unified framework for licensing all midwives – both nurses and direct-entry midwives.
But this is the exception to the current trend, and, in fact, the New York rules pre-date
the establishment of the CPM credential.
More states are adopting the CPM credential as a requirement for midwifery licensure,
and not the CM credential which both ACOG and ACNM recognize. Of the roughly 21
states that license midwives to attend home births, all use the CPM credential. By their
lack of training and because they do not work collaboratively with hospital-based
obstetric providers, CPMs are the least qualified midwives to attend a home birth.
The Midwives’ Advantage
􀂃 Strong support among conservative lawmakers.􀂃
Gotta love my peeps the conservatives!
Different titles for midwives & different levels of training foster public confusion
and work to the midwives’ advantage in the legislative arena.
􀂃 Legislators respond to the home birth “choice” message.
A clear trend shows support for home birth among conservative and Republican
lawmakers who don’t see much difference between home schooling and home birthing.
Where these lawmakers hold the majority, home birth bills get passed.
The American Legislative Exchange Council (ALEC), an influential 2,400 member
organization of conservative state lawmakers, recently endorsed a model bill for the
licensure of CPMs. Model legislation developed by ALEC gets wide attention in state
legislatures across the country.
Legislators often cannot distinguish between different types of midwives.
This is code for: Legislators cannot flesh out the midwives who have been sanitized and endorsed by US, so how can these bumbling idiots figure out how to pass decent laws!!!
The different titles for midwives – direct-entry, independent, certified midwives, certified
professional midwives – foster public confusion. This tends to work to the midwives’
advantage in the legislative arena. Legislators often cannot distinguish among different
categories of midwives and have a distorted impression of the actual qualifications of
these practitioners.
The different credentialing standards for nurse-midwives, certified midwives, and
certified professional midwives are not well understood by legislators. ACOG’s joint
statement of policy on nurse-midwives and certified midwives is being misused by
midwifery advocates to support other midwives and home birth.
There is wide variability in the legal status and level of practice authority of midwives
across the country. States in the northeast and northwest, along the southern border, and
in the Appalachian region have long-recognized lay midwives in some legal or quasilegal
capacity. This situation complicates our advocacy. For example, in their testimony
before state legislatures, midwives frequently cite Washington State because it has
relatively liberal laws on lay midwife practice as compared to the rest of the country.
Legislators respond to the home birth pitch — “choice” and “safety”.
To bolster their case for licensure, midwives like to cite European countries’ experience
with midwives and home birth. This may play well with an uninformed public, but the
analogy is flawed. The conditions that make home birth relatively safe in some countries
– the Netherlands for example – do not pertain to much of the US. The Netherlands is a
geographically small, densely populated country where everyone lives within 20 minutes
of a hospital.
In their recent testimony to state legislators, midwives have been citing a 2005 study on
the safety of home births by direct entry midwives in the US. (Johnson KC, Daviss B.
Outcomes of planned home births with certified professional midwives: large prospective
study in North America. BMJ 2005;330;1416) This study concluded, “certified
professional midwives achieve good outcomes among low risk women without routine use
of expensive hospital interventions.” ACOG continues to assert that studies comparing
the safety and outcome of births in and out of the hospital are problematic, not
scientifically rigorous, and unconvincing. (See, ACOG Statement of Policy, Home Births
In The United States, May 2007.)
Midwifery proponents in the state legislatures don’t fit any single profile.
Recently, we’ve seen some odd-ball coalitions. Missouri exemplifies a nascent trend
among the states. In 2005, a midwife bill (HB 36) was championed by an unusual
coalition – Republicans, including the Speaker of the House, home schooling proponents,
the religious right, and the state’s Amish and Mennonite communities.
The bill language was deceptive in its simplicity. It said,
“Nothing in Missouri law shall encroach on a mother’s right to give birth
in the setting and with any caregiver of her choice.”

Sounds like a great bill for the whole country, heck, the whole world!!!
ACOG on the Defensive
􀂃 Bills don’t get defeated on the merits.
􀂃 Midwives show-up in huge numbers & their testimony plays to a sympathetic
public and press.
􀂃 Nurse-midwives are a fickle ally.
􀂃 Physician back-up and declining availability of VBAC complicates ACOG’s
advocacy.
ACOG is playing defense on most of these bills. It’s the rare situation where we can
defeat these bills on the merits.

Ha ha ha ha heee hee hee snort haaaa
For example, in Missouri, ‘lay’ midwife bills get introduced year after year. These bills
have been stopped – up to now – mainly by deft political maneuvering and hardball
tactics employed by the State Medical Society, not by any persuasive testimony about
comparative safety or quality of care.
In more and more states, doctors have been out-maneuvered in the legislative hearing
room. Midwives tend to show up in huge numbers (and not just on the day of the hearing
but almost on a daily basis throughout the session) and their testimony plays to a
sympathetic public and press. In a few states, a show of force by the medical community
might clinch victory; but in most it only reinforces a perception among lawmakers that
this is just a turf battle between doctors and non-doctors and the final vote tends to favor
the latter.
Nurse-midwives – a fickle ally.
The American College of Nurse-Midwives (ACNM) and its state chapters are divided on
their response to state legislation that would license CPMs and legalize home birth. This
complicates ACOG’s advocacy. Whereas nurse-midwives have been ACOG’s front-line
defense against these bills, that’s no longer a sure thing. Today, you don’t see nursemidwives
speaking with any consistency against home birth or the certified professional
midwives (CPMs). There is a widening internal debate within the American College of
Nurse-Midwives over education and training standards for midwives, and ACNM and
MANA do not agree on certain aspects of education and practice.
Physician back-up.
Physician back-up for midwives and out-of-hospital deliveries is a growing concern in
some states. In Wisconsin, the professional medical ethics of physicians who choose to
back-up CPM-trained midwives were in dispute over home birth legislation that got
approved in 2006 over the objections of the Wisconsin ACOG Section, the state AAP
Chapter, and the State Medical Board. The bill passed with the support of the State
Medical Society and an ob-gyn serving in the state legislature.
Another example is California. In 1993, California licensed midwives to do home
deliveries under physician supervision. But implementing regulations for the 1993 law
were only recently finalized after years of wrangling over key issues including the
physician supervision requirement in the authorizing legislation. Medical liability
insurers in the state were refusing to cover physicians who back-up midwives and
midwifery proponents in the legislature threatened to waive the requirement for physician
supervision altogether.
Declining availability of VBAC.
The situation with hospitals declining to do VBAC deliveries has complicated our
advocacy efforts on midwives. ACOG Fellows in California, Washington and other
Western and Rocky Mountain states report that women are seeking out alternatives,
including home birth with midwives, in their desire for a VBAC. The VBAC issue was
one of several sticking points in California as stakeholders weighed-in on regulations to
implement a midwife licensure law.
Maybe we shouldn’t have outlawed VBAC….it seems to have pushed women over the edge. But hey we all were thinking that when we put the pastel wallpaper in the birthing suites the mothers wouldn’t notice when the c-section rate hit thirty percent. Who Knew???

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