ACOG v. Midwives, Part a Million
Sunday, December 5, 2010 at 12:54PM
By emjaybee
Via @pushformidwives on Twitter, we have this rather interesting news story from Illinois PBS station WTTW.
Watch the full episode. See more Chicago Tonight.
While The Unnecesarean is not technically a homebirth/midwifery advocacy blog, this clip is notable both for the reporters’ somewhat alarmed tone while discussing CPMs and homebirth, and for an appearance by Dr. Jacques Abramowicz, (also quoted in this related article) the Illinois chair for our old friends ACOG.
ACOG is where the push for access to midwives, right to homebirth, for lowered c-section rates, and for less intervention-heavy births intersect, in that they are the organization most opposed to all of these reforms. This has had the, for them, unfortunate side-effect of broadening their opposition. Women who would never consider homebirth or a midwife find themselves making common cause with women who do advocate for those things, merely so they don’t have to undergo abusive treatment in the hospital or unnecessary surgery. The woman at the beginning of this video, in fact, is having a homebirth as a direct result of a previous hospital experience (though we don’t know if it was a c-section).
Having said all that, I would LOVE a CPM to deconstruct Abramowicz’s assertions that CPMs reach certification without ever having seen a breech birth, among other things. Also that it takes an OB 15 years of training before they’re allowed to deliver a baby—can anyone offer an idea as to where he got that number?
Oh, and in the WTTW comment thread mentioned at the end of the piece you can find, among overwhelming support for CPM licensure, this snarky gem by midwife Linda Simon-Price:
I am one of the nurse midwives filmed in your piece - I am wondering why physicians are always interviewed to discuss the ‘safety’ of midwifery care. Instead, you should have contacted someone from the American College of Nurse Midwives, our governing body, to discuss CPM’s and their role in birth and especially home birth. This never makes sense to me. It’s kind of like asking a plumber to comment on electricians. Both tradesmen, but completely different jobs. You allowed him to talk about the ‘dangers’ but didn’t back that up with statistics, that shows that home birth is a very safe alternative for low risk women. No one ever talks about the bad outcomes that occur in a hospital setting. If women were not so afraid of the experiences they have come to expect in hospitals or faced with a more than 30% c/s rate in this country, or had the opportunity to use a free standing birth center in Illinois, then there would be more options available to women. Just sayin.
Related reading:
Illinois’ Home Birth Safety Act (SB 3712)
Reader Comments (21)
First, I haven't had a chance to look into this yet, I'm on a slow connection and it will boot me off.
As a student midwife, I can see to a point that some CPM's will not see a breech birth or other variations of normal labors before becoming certified because they practice in states where a licensed midwife must transfer these. Of course you have patients who show up in labor with a breech, but I think those are fewer, especially in such small percentage of women who are attended by a midwife.
And I'm not quite sure where he got 15 years from. A medical student will start doing clinical rounds in about their 3rd year of med school, so 7 years in college after graduating high school. So technically they can start delivering babies then, and when they're in residency. Not being "allowed" to catch babies before then is like saying midwives can't catch babies until after they're licensed. And who wants to be the first patient for that?
If they go on to be an ob/gyn, they'll have their residency that averages another 4 years. That's still only 11 years by my count, and that's to be a licensed physician on your own...you'll definitely be allowed to deliver babies LONG before that point. Maybe math wasn't his strong point?
I think it's also important to note that Ob/gyns are not the same as midwives, they're trained surgeons. I'd expect the person who was going to do a major abdominal surgery on me to have more training than a midwife, because the demands (knowledge, technique, risks, etc.) are different.
I think the 12-15 year "quote" was a misunderstanding aka poor journalism skills. Because it was not said on camera, it is hard to know what was said. After 4 years of college and 4 years of medical school, they typical OBGYN resident starts delivering babies in the beginning of residency (4 more years). Perhaps Abramowicz said something along the lines that OBs do not deliver babies independently until they graduate after 12 years of school and training (15 years for maternal fetal medicine specialist, who do 3 years of fellowship training).
He was likely saying that CPM have 3 years of training and OBGYN have 12-15 years of training.
However, that exaggerates the education of OBs. In what way do the courses taken in college prepare an OB to deliver a baby? Same with much of medical school, which involves training and clinical rotations in many other specialties. And it ignores all the high-risk training and education an OB GYN needs (managing complex pregnancies and medical complications, performing cesareans and hysterectomies), plus education in GYN care, both simple and complex, including GYN surgery GYN Oncology, none of which is in the scope of practice of a CPM.
Abramowicz is totally ignorant of the training of CPM, claiming they are not trained in neonatal resuscitation or management of Post partum hemorrhage or cord prolapse. All CPMs are trained in recognizing and managing complications during and after birth.
Just guessing 15 years = 5 years high school, 4 years university, 4 years med school, 2 years specialization??
And when do OB's see a breech birth?
I KNEW I recognized that midwife's office. I did my ALACE training at Mother Me, Inc. I learned to listen for FHT in that office :)
"And when do OB's see a breech birth?"
There are some out there who will.
Uh, I've been a doula for only six months and _I_ have already seen a breech birth. Home is where the breeches are being born...so CPMs have many, many occasions to attend a breech. Way more than OBs would get, I surmise, and it's their own fault!
I have worked at University of California Irvine, Medical Center for 24 years. 4th year medical students are allowed to deliver babies. First year Obstetric Residents are given all the normal vaginal deliveries, unless the patient has emphatically stated that their doctor must be there for the birth. It is ridiculous to say that an obstetrician doesn't deliver a baby until 15 years of training. That is an outright lie. We had a 8 - 5 p.m. midwife for about a year who did all the normal spontaneous vaginal deliveries until it became clear that the med students and residents were not getting their share of the deliveries. She was gone almost overnight after they determined that our number of births per year had dropped and there were no longer births to spare. You would not believe the horrible things that are done to women in a medical school environment. It is appalling. It does not surprise me that obstetricians lie in an article that deals with the issue of women re-claiming control of their health care. They do far worse in the clinical setting. I have experienced it first hand for years.
Here's the exact quote from the piece at the 03:27 mark:
"Dr. Abramowicz says that a physician may go through 12 to 15 years of training, including medical school, before delivering a baby."
That seems like a pretty straightforward quote. It's possible the reporter got it massively wrong, of course, so I suppose we'd have to ask Dr. A directly to be sure. But surely you cannot count most of undergrad (much less high school) as medical training and if you could, every college-degreed CPM would qualify. I'm wondering if he did not mean "deliver a baby" so much as "perform a c/section" perhaps?
I agree that that math seems a little off. And is it really fair to include undergrad in the calculations?
I'm thinking about going into being a CNM eventually, so if I were to include my first bachelor's plus at least a year getting pre-requisites, plus getting CNA certified, plus a year of nursing school (most programs would be 2) and then, I don't know, maybe 3 years getting a masters - that's like 9 right there. Some physicians need to get over themselves.
" I am wondering why physicians are always interviewed to discuss the ‘safety’ of midwifery care. "
I wonder about this, too. I remember the interviews of OBs done for The BoBB and the OB would be talking about how unsafe home birth is, then ask something like, "I mean, do they even do fetal monitoring at a home birth? Bc I wouldn't know since I don't do it." It seems so wrong that a) someone who has NO CLUE is making statements about its safety, and b) about 10 minutes of reading online would answer that question. It amazes me how they can bad-mouth a practice they have no interest in learning more about (so they can know what they're talking about).
As an OBGYN, I can attest that we start doing deliveries very early in our careers, often with varying degrees of supervision. In fact when I was in medical school, the labor floor was so busy that my first delivery was also the first one I had seen, since 2 other women were delivering simultaneously, and the very experienced labor & delivery nurse coached me through it. (I would note that the medicolegal climate has changed since then and this sort of occurrence is now a rarity.)
We also had midwives working on the unit which gave me an early exposure to that type of practice, and certainly instilled in me confidence in their skills and abilities.
A vast majority of our training as an OBGYN is not in normal deliveries but in taking care of sick women, either with GYN related disease or women with high risk pregnancies. Therefore, the majority of the laboring patients we care for have been referred to us from other hospitals and practices, due to their degree of risk. We learn a great deal from seeing these kinds of patients in a concentrated environment, surrounded by experienced attending physicians, but it gives a skewed perspective on normal birth.
It was likely not until I practiced in New Zealand, which has midwives as the primary caregivers for pregnant women, and no history of malpractice lawsuits, that I really was able to witness normal childbirth. The obstetricians, of which there were few, only looked after the high risk patients, or came in when there were issues. Many women chose homebirth and few of these required transport to the hospital. I did not witness or hear of any catastrophes, and the statistics for that country for newborn outcomes exceeds that of the US.
I believe Marsden Wagner said that having an OBGYN attend normal deliveries of low risk women is like hiring a pediatrician for a babysitter, in case the child should get sick. The New Zealand model recognizes this an reserves their doctors for the women who truly need them.
I feel strongly that a system which allows deliveries by well trained midwives, who have a collegial relationship with a supportive physician community is a safe one and is far preferable to treating women who opt for homebirth as outsiders and their caregivers as criminals.
The biggest hurdle however is educating the OBGYN community, and I am afraid that once prejudices are established early in one's career, it is nearly impossible to eradicate them.
So no, we don't train 12-15 years before delivering babies, and at the end of that training, perhaps only 1-2 years is actually spent attending deliveries, which brings the CNM or CPM's training in childbirth a lot closer to ours. Knowledge of ovarian cancer staging, or the ability to perform a laparoscopic hysterectomy does not make me a better caregiver for the patient in labor, and yet the midwife's focus on facilitating the normal birthing process in healthy women does lessen their chance of adverse events, and this mode of care should at the very least be an option for women.
As someone who had a first labor at our nearest teaching hospital and is planning my second birth now as a homebirth with a CPM I can tell you that residents-on-call surely do sometimes see a "breech" birth - well, not actually a "breech birth" - in my particular situation, here is what our residents training got me...the completely all natural labor I worked so hard for - my body worked perfectly w/out assistance...there was an ultrasound during labor - and another at the end of labor - to be certain of position I gather. Ironically - on my second "push", one of the fabulous residents yelled "STOP PUSHING - THAT'S NOT A HEAD!" They told us (ALL they told us as I tried NOT to allow my son to come out naturally as they said "DON'T PUSH!!!" was "We know it's the opposite of what you wanted - but none of that matters anymore - the baby's in DANGER and we have to get him out NOW!" NEVER, never, never, never did they say they were afraid to deliver breech/head entrapment or anything giving us ANY option of continuing to allow my son to come out on the path he was already so FAR down! My medical records say exactly that - that they discussed that with us - as someone SCARRED by my son's birth in multiple ways - physically and emotionally - I can tell you that they did not - there was no "informed consent" -no signed consent form - only absolute fear and lack of knowledge when they saw a breech baby coming. I had an emergency cesarean under general anesthesia and was literally UNCONSCIOUS when my son was born. My uterus was working so well/contracting so strongly that ironically (the "fear" they were trying so hard to avoid w/vaginal delivery), his head was stuck in my uterus and they had to extend my incision and then create another vertical cut - leaving me w/a "T" incision. I went from a Mom with a 100% healthy pregnancy and labor to a walking risk for my second birth - which I'm joyfullly planning now with conscious self-prenatal care and CPM visits while I plan my homebirth. My son - who was frank breech by the way - the "best" breech position to deliver vaginally - is 5 years old now - I STILL cry about and grieve his birth. When birth matters to you, you do ALL the work you should - and are let down by the experts in place to care for you - it can literally change your life forever. It was NOT an option to have to deal with being seen as a "walking risk" in a hospital setting this time around - SO MUCH was taken from us the first time around with one decision - MADE BY SOMEONE ELSE - as their was no true informing - and no true consent by us - that there was NO WAY I was going to listen to all the reasons why what they LEFT US WITH from our first birth determined that our second birth would also be a second cruel punishment.
I had done TONS OF RESEARCH prior to deciding on my path - the first two trimesters of this pregnancy were frought with STRESS as I worked to make the BEST decision for our family. I am SURE I am just a "blip" on the memory screens of those physicians. Their lack of training and experience with breech births - and assisting a natural vaginal breech birth that was GOING PERFECTLY - changed my life. As another provider hearing my story said "I can't believe they thought it was a better idea to push him BACK UP and go through major surgery to get him out rather than just let him be born.
I don't know WHAT OB's this article is talking about - and in fairness I have heard that older more experienced docs *MAY* be willing to do breech births - but they're few and far between. Otherwise - I've been told OVER and OVER that they're simply NOT TRAINED in vaginal breech births anymore.
I had to speak to the "having seen a breech birth" point as I have been so affected - and have had SO much feedback from other professional re: that subject and how it's simply NOT TAUGHT.
"Whenever I speak to group of obstetricians and mention the words 'home' and 'birth' in the same sentence, there's always hysteria. But then I will ask them to show with a raise of hands how many of them have ever seen a home birth. Well there are no hands raised. So I will tell them they are like the geographers who try to describe a country they've never been to because they are too afraid to go there." ~Marsden Wagner, MD
Kimrose - Its sad that less and less OBs are trained in vaginal breech delivery, but that's due to the malpractice climate out there.
As someone who was trained in and still performs vaginal breeches, I wanted folks to know that we're still out there, but you have to do your homework. All breeches have a higher risk of complications, but knowing how to deal with them vaginally should still be an integral part of the training.
Dr. Abramovitz's figures were definitely off - it was either a gross mistake by the journalists or a lie by the doctor. Why is it that doctors in the U.S. seem to think of birth as an illness; it is a perfectly natural thing. MD's are looking for what's wrong and not what's right. My daughter has had 4 homebirths, the first were twins, and they weighed 6 lbs and 6 lbs . 4 oz. There is no reason for all of this intervention. The U.S. has one of the highest infant mortality rates and highest C-sections rates in industrialized countries, which should tell us something. We are not doing it right. We should look at the countries that have better outcomes and we will then see that many of them are homebirths. Go figure!
I had a C. Section for my second==10 lb 9 oz--I had REALLY tried to get induced after steroids at 37 weeks because my first baby was 9 lbs 2 oz and I pushed for 5 hours (no epidural) and ended up with a NEEDED (I was EXHAUSTED!!) forceps delivery. I induced myself outside the ER parking lot with my third and walked in at 7 cm and delivered--the C. Section was so traumatic it was at least 3 years before I could talk about it without tears---I felt that early INTERVENTION (the breast pump and castor oil all did NOTHING)would have PREVENTED my C/ Section.
If your CPM KNOWS about the T incision on your uterus --why aren't you a "risk-out" for home birth?--are you considered low risk in her books---does not seem congruent with what I am hearing about CPM birth eligibility. There ARE some of us doctors out there who can at least REALLY try to give you your VBAC--but-- as I found out this Thanksgiving--have back up just around the corner. It was my first rupture (since residency)--but it was with a good outcome---would it have been so good if mom had to be transported from a home birth situation---I don't think MY patient's rupture would have tolerated even 15 mins.
I am VERY patient---a 5 hour second stage while waiting for a head to rotate is not unusual. My record for second stage is 9 1/2 hours --she DID have an epidural (HER choice), and had no urge to push--so I let her labor down while she slept, and in the end only pushed 20 mins and no stitches.
One lawsuit here in the USA though can TOTALLY wipe you out FOREVER---so have a heart---I would LOVE to save 80K a year in malpractice premiums and have a midwife system like in England or New Zealand. I envy midwives---able to do deliveries and not have to carry malpractice---how did they get so lucky???
Wow "Michelle" -
Re: your comment "If your CPM KNOWS about the T incision on your uterus --why aren't you a "risk-out" for home birth?", etc., etc.
without a SINGLE reference to why trained OB's thought it was BETTER to push my emerging frank breech baby BACK UP and deliver him via emergency cesarean under general...hmmm....lawsuit? - guess what - I DON'T CARE - if "lawsuit" is a major decision maker in how to best care for moms and babies then women are RIGHTFULLY wary of the "system".
I spent the first two trimesters of this pregnancy researching EVERYTHING about my "T" incision and this birth - so PLEASE, PLEASE, PLEASE do not begin to offer your "expert" opinion on why I do not "deserve" or should not be "allowed" a better chance at birthing this baby naturally. Thank GOD there are evidence based providers who pay attention to actual evidence based outcomes and risk factors and practice according to THOSE numbers and truths.
We all need to be able to live with our decisions - my decision to be in a "teaching hospital" for my first birth - with the assurance that my doc. would be there for the birth regardless - almost certainly changed my son's birth story - changed my life story - period. I get to make a different choice this time - shame on you for still clearly thinking that it should be someone else's right to make that choice for me.
I am NEVER so harsh with comments - but found yours particularly offensive to an almost-8-months pregnant woman who is VERY INFORMED - and only wishes she had pressed delete when reading the email w/your "comment".
Kimrose, the comment came from Helen, who is an OB.
Jill - YES, YES - I KNOW :0 :( I realized immediately after I posted that names are grouped under/following the post - but couldn't edit/delete it - if you can/could I would happily re-submit it!
***CLARIFICATION that my original comment was intended/in response to "Helen S" and not Michelle Roller!!!