From Lee Passman:
It is very condescending to talk about Internet Crazy Mamaz and Lactivism, etc.
If you want to give medical advice, take your exams. Don't take money for spreading propaganda.
From Jolene:
"But why can't the midwife use the same monitor as in the hospital?"
Uh, because the midwife can't afford to rent / buy / maintain those kinds of monitors to use one-at-a-time and then sit dormant the rest of the time? Because they can't get wheeled in and out of a private home? Because they require specialized maintenance?
Why not ask while you're at it, how come your midwife doesn't bring her own mammogram machine or ultrasound machine to your home? ROFL!"
Susanne, it is clear you haven't a clue in this area. I personally know several midwives and each owns (and brings with them) a portable continuous monitor. It is about the size of a bread box. (if the mother uses it is up to her it is not required to be used by midwives in our state. But that's something that could be mandated in your state... should you legalize midwives) It's true I have no idea what they would cost. I'm surprised your husband doesn't have one in his office.
The point is. Now that homebirth advocates are lining up at CharlotteDad's door to get his support for their homebirth.... he can support making certain requirements manditory if he votes for midwife legality in his state.
From Jolene:
"Why choose a provider who can do A only imperfectly and B not at all, when you can choose a provider who can do A and B AND is in the setting that accommodates both A and B? Seems rather dumb to me."
I don't know why someone would choose one. That wasn't the question. Why do people choose tea over coffee? If it's legal, it's none of your business why they choose it. And if it's not, then you can decide to keep it illegal until certain things are met that satisfy you, such as the monitor idea.
"What was it about .. oh yeah you were "offended" at me suggesting that people should not intentionally try to have children they can't afford. Hmm, that's come up in the news recently hasn't it?"
Yup. read back a few hundred posts. We discussed it here too. And your viewpoint isn't a popular one. Darn.
From Jen:
"And your viewpoint isn't a popular one. Darn."
It isn't? I thought he said someone shouldn't intentionally have kids if they can't afford it? I read and took part in the conversation here about the octuplets, and I don't remember anyone really saying that they disagreed with that sentiment. Susanne mentioned that she thought the real outrage was the doctor, and that she would still find it wrong even if the mother had been well-off. On Dr. Amy's Open Salon blog, most people were also outraged over the fact that she purposely brought more children (let alone 
into the world when she could hardly afford the six she already had. Those who weren't outraged tend to say that it just wasn't any of our business, regardless of the situation. There may have been a few that felt there was no problem with it at all, but they were certainly in the minority.
From Jen:
Smiley with glasses was supposed to be an 8 obviously, lol.
From CharlotteDad:
Jolene, I read back at those some time ago and again before I posted, and it is as Jen said. Where was your outrage then?
Darn indeed.
By the way, why didn't you go over to Open Salon and tell them how offended you are? The comments there were downright brutal compared to what I said a while back on here. Here is Dr. Amy's post:
http://open.salon.com/content.ph....php?
cid=106429
Give 'em hell!
From Susanne:
Susanne, it is clear you haven't a clue in this area. I personally know several midwives and each owns (and brings with them) a portable continuous monitor. It is about the size of a bread box. (if the mother uses it is up to her it is not required to be used by midwives in our state. But that's something that could be mandated in your state... should you legalize midwives) It's true I have no idea what they would cost. I'm surprised your husband doesn't have one in his office. "
Of course he has a monitor in his office. There is also a fancier schmancier big one in the hospital for laboring patients.
From Susanne:
"And if it's not, then you can decide to keep it illegal until certain things are met that satisfy you, such as the monitor idea."
Well, here's a start: Require all homebirth midwives to be CNM's. The programs already exist and are well-regarded. What's wrong with that idea?
From Jolene:
"Well, here's a start: Require all homebirth midwives to be CNM's. The programs already exist and are well-regarded. What's wrong with that idea?"
Not a thing. But even CNMs are not required to carry the monitor to home births in my state. (have the same requirements as non-CNMs) Wouldn't that be another good idea?
From Alexis:
Jolene, I have to say, offering cEFM at home seems to be really rare. I've never heard of anyone having it. Most home birth midwives (including CNMs) don't really believe it's necessary for routine births and if you showed signs of needing it (according to the usual protocol) they'd want to transfer you to the hospital anyway because you're no longer a standard low risk labor.
About the only use I could see for it is in a VBAC which is supposed to be cEFM... and even then, uh oh if you do see problems.
From Liz:
The fact is there are certainly (one supposes) excellent cautious midwives around and poor or inattentive or harassed hospital staff. But that doesn't, cannot mean that homebirth is safer than hospital when things go wrong. Neither my child or Melissa's would have fared better in a homebirth, and no, that does not mean it was inevitable, nothing to be done, or easily assimilated into a philosophy of "taking responsibility".
I have to say that my eyebrows did go up when I read the original "Failure to rescue" post - because it does happen in hospitals. Not often, and it should be never. But it really does reinforce the point that bad things can, rarely, happen so quickly, insidiously and unpredictably with such devastating consequences that the argument that homebirth is nicer seems very thin. I have read posts here from very conscientious midwives who would clearly never want to put a woman at risk. And some, not necessarily here, who want to deny that the risks of such things as breech, PPH, etc. are much of a problem. So yes, homebirth can and should be made "safer", but as far as I am concerned, the midwife model of care rests on some flawed assumptions. In theory, there are two options - make homebirth safer, or hospitals nicer. Neither is likely to please everyone, but the latter is likely to result in fewer catastophes.
From Susanne:
If you're just going to have cEFM at a homebirth with a midwife, why can't you just get your ass to a hospital and do the same thing? Then the argument for homebirth just becomes trivial - it's more warm and fuzzy and I like my own wallpaper better - which is not an argument for all.
Just think how loudly the natural-birthing crowd would cry at the Intrusion of Making Their Midwives Do cEFM at Home, Their Sacred Garden of a Precious Home. Freedom and liberty for my precious pregnant belly, which I just *know* is going to be perfect, until it isn't!
From Jolene:
"Just think how loudly the natural-birthing crowd would cry at the Intrusion of Making Their Midwives Do cEFM at Home,"
The problem is, it's not a requirement at the hospital either. (I declined, and so do many women) So you can't legislate something to happen at a homebirth if it isn't legislated at a hospital.
However, I do think that having a strip of paper for legal reasons would either be a great boon to homebirth midwives or sink the whole profession. Either way, to me it looks like a good idea.
From Jolene:
"Jolene, I have to say, offering cEFM at home seems to be really rare."
I think it probably depends on which state you live in, if the attending midwife is a CNM or Licensed, or not licensed.
I won't say it's "standard of care" at home. The midwives I know who own them seem to think they are cutting edge for having it. However, I don't know how much ACTUAL use they get out of it, as most women decline. One midwife I know hopes it becomes possible soon to send the strip electronically to the hospital ahead of time during a transfer. (or for a consult) Honestly, I don't know if it's the technology that can't do that yet, or if there isn't a "system" in place to do it yet.
From Alexis:
FWIW, I'm in New York--our midwives are all CNMs or CMs.
From Susanne:
"The problem is, it's not a requirement at the hospital either. (I declined, and so do many women) So you can't legislate something to happen at a homebirth if it isn't legislated at a hospital."
That's not a correct statement. Why couldn't one?
From Susanne:
"One midwife I know hopes it becomes possible soon to send the strip electronically to the hospital ahead of time during a transfer. (or for a consult) Honestly, I don't know if it's the technology that can't do that yet, or if there isn't a "system" in place to do it yet."
Why should the hospital be interested in introducing (and bearing the costs of) such a system to benefit the homebirth midwife who isn't on staff at their hospital? Hospitals aren't in the business of rewarding amateurs who want to play practice medicine.
From Alexis:
Susanne, that assumes that the hospital would bear the costs. I would assume that a hospital (in the US anyway) would not bother as it wouldn't be cost effective, and I don't think the midwife would make that assumption either--especially as it would be useless if each hospital had to have a special system; you don't always know in advance where transfer will be or if you'll have a choice. Perhaps the midwife was thinking that this might be possible with some type of electronic records system which the hospital would install for the benefit of all patients, rather than a specific system just for home birth.
Also, cheap shot. Let's not forget that in some areas, CNMs do home birth and they are neither amateurs nor playing at medicine. Is it possible for you to argue without being obnoxious and condescending?
As for EFM at the hospital, they can't force you to consent to any individual procedure, and in active labor they can't just kick you out. Let's not forget that liability controls everything, and I don't think a hospital would have a very good case for "EFM or no care at all".
From Yehudit:
Why would anyone want to do cEFM at a homebirth? Intermittent monitoring is standard of care in UK unless there is a specific indication for cEFM. Being in labour is not an indication for cEFM - routine use for all labouring women does not improve neonatal outcomes.
If you have an indication for using cEFM then you probably shouldn't be at home.
From Susanne:
I'm referring to DEM/CPM's. Not CNM's. Sorry for the confusion.
If midwives think they can get enough trust on the part of the hospitals that they know what they're doing and so that hospitals should back them up by agreeing to read their strips remotedly (assuming the technology exists) and providing the "back room ready to go", more power to them. It's not going to come without some assurance of quality control on the part of the hospital, though. DEM/CPM's certainly aren't going to get that trust on the part of hospitals.
From Alexis:
The thing is, though, the midwife (who may have been a CNM for all you know) wasn't talking about doing this routinely--she was talking about basically sending records ahead of a transfer. From the sound of it, the transfer is going to happen anyway, so it's to the hospital's benefit as much as the midwife's if they have the records and trace. I don't think she meant she was going to use it the way remote monitoring is used in hospitals--if you're going to have EFM at a home birth, I should think you'd need to know how to use it.
(Actually, thinking about it--are most DEMs even trained to use EFM and interpret the trace? It's really considered part of "abnormal", hospital based birth. Most DEMs won't even encounter EFM enough to have any confidence with interpreting the strip, except for those few who worked L&D and went for a CPM instead of a CNM for whatever reason. I'm thinking that any midwife who shows any enthusiasm for actually using EFM has to be a CNM, probably one with hospital experience, either as CNM or L&D.)
From Alexis:
(By "EFM" I mean continuous monitoring/CTG - of course DEMs are trained to use a Doppler or fetoscope, but AIUI, learning how to read and interpret a CTG trace is different.)
From Jolene:
I won't cut and paste each piece here, but it was my understanding that the strip would be sent electronically (over the internet??? I don't know how medical records are sent from one location to the other) There is one piece missing (medical records system? technology doo-dad?) which does not allow that to happen yet.
Training to read EFM is available as a class from the company you buy the machine from, and probably elsewhere as well.
Susanne, your constant assumption that DEMs are not and cannot be integrated into the healthcare system is tiresome.
Midwives have full transfer abilitys and authority here, and you better believe they prep the OR when a midwife (DEM or CNM) calls and asks them to.
From Alexis:
Jolene, I've seen labor nurses post here before that interpreting EFM strips is a skill that's learned and has to be practiced. You develop a feel for it by doing it, day in and day out. You may learn the basics in a course--whether from the manufacturer or on one of AWHONN's courses. But as with any health care skill, I'd prefer to put my eggs in the basket of someone who's had to use their skills.
From Alexis:
Oh, and DEMs can't be integrated into the healthcare system as long as they don't want to be, or as long as they think that they can benefit when they want to but not have to give in when they don't. If they want to be integrated into the system they need to improve their training and oversight, and they need to stop this routine about hating the "medical model" of birth except when it benefits them.
From Indy:
... and maybe when they start carrying malpractice insurance and start accepting responsibility for their own errors.
Practicing medicine is fun when you don't have to do all the school stuff or pay for licenses or insurance. There is a reason they want to keep their distance from formal medicine and it isn't ideological.
From Jen:
"Training to read EFM is available as a class from the company you buy the machine from, and probably elsewhere as well."
As Alexis said, Jolene, reading an EFM strip is not something easy you pick up with a class from the manufacturer. I work at an insurance company that does medical malpractice and have seen how easy it is for someone to interpret a strip far differently from someone else (and the outcomes can be pretty bad). It's more of an art than something you just learn from a class.
Can anyone tell us how L&D nurses are normally trained to read the strips? Do they have a period of apprenticeship (like a residency) where they would watch others interpret strips before they have to do so themselves?
From Susanne:
"Training to read EFM is available as a class from the company you buy the machine from, and probably elsewhere as well."
LOL, Jolene. Reading an EFM strip is a skill. Even practiced labor nurses may have difficulty in doing so. It's not a simple matter of this is up and this is down.
"Susanne, your constant assumption that DEMs are not and cannot be integrated into the healthcare system is tiresome."
But they aren't. Their certification / degrees don't mean anything, because their "schools" are the equivalent of Mary's Midwifery and Bait Shop. Why should they be meaningful to a hospital whose other healthcare employees went through real training and education and licensing to hold their titles?
Do us a favor, Jolene. Find us a DEM school that you think counts as "sufficient" or impressive education, compared to a CNM program.
From Yehudit:
The thing is, though, the midwife (who may have been a CNM for all you know) wasn't talking about doing this routinely--she was talking about basically sending records ahead of a transfer. From the sound of it, the transfer is going to happen anyway, so it's to the hospital's benefit as much as the midwife's if they have the records and trace.
+++++++++
This doesn't make sense to me. If there is an indication for doing a CTG trace (e.g. meconium in liquor, decels heard on auscultation with sonicaid) then she would want to transfer anyway, and waiting for twenty minutes or so at home while you do a trace and send it electronically to the hospital is simply losing time.
From Jolene:
You forget that we in the US use the monitor for many more things, including legal reasons (VBAC?)and simply to feel like the doc/midwife is "doing something".
Some midwives or mothers may prefer constant monitoring to IA.
And if, as the accusation goes, the ambulance takes 20 minutes to arrive, why not take a trace during that time?
From Jolene:
"Susanne, your constant assumption that DEMs are not and cannot be integrated into the healthcare system is tiresome."
But they aren't. Their certification / degrees don't mean anything, because..."
Susanne, do me a favor and explain why some states license and integrate DEMs? Do they take extra training over their regular "schools", or pass extra exams, or what? Why do the hospitals here prep the OR when a DEM transfers?
From Jolene:
"Jolene, I've seen labor nurses post here before that interpreting EFM strips is a skill that's learned and has to be practiced. You develop a feel for it by doing it, day in and day out."
I'm certain that is true. Would a homebirth CNM be incapable of interpreting a strip then? What if it's been 2 years since she worked in hospital? 5? How about if she currently also picks up odd shifts in a hospital to suppliment her homebirth income? What if she works full time in a hospital and does homebirths "on the side"?
Should any of these CNMs be disallowed from using a monitor at home? Or should they be required to use one, as Susanne suggested upthread? After all, if they use it on each homebirther they won't loose their touch as quickly, right?
From Jolene:
To quote myself: Susanne, do me a favor and explain why some states license and integrate DEMs?
I live in a legal and sanctioned DEM state. I have never considered using one, nor would I. However a good number of people do use them. When I met the CNM who delivered my second child, she suggested to me that I may be happier using a DEM at home. (because I described my preferences right up front to avoid any confusion)
I think that says something that a hospital CNM can recommend a homebirth DEM in a "public" way. (we were walking down the clinic hall)
My point with this is, once DEMs are regulated and integrated into the system, the public has much less say in requirements for their licensure. CNMs are not calling for more stringent requirements for DEMs because the requirements are the same for both CNMs and DEMs, and they would, in effect, be limiting themselves as well.
For this state to suddenly say "Oh, never mind, all homebirth midwives have to be CNMs" just wouldn't work.
And it is much easier in Susanne's state to say "Look at Jolene's state! It is working there, it can work here" and actually get DEMs legalized, than it is to remove licenses from DEMs who already have them here.
It is absolutely useless to discuss how DEMs can never be integrated... because in places they already are. (and a good number of CNMs support dropping the nursing requirement as well) A much more constructive discussion might be how to limit or supervise or raise the bar for their training in ways that are palatable to you, and to the people of your state. I've seen it suggested that the CM become the accepted credential in states looking to legalize DEMs. I support that idea. Any others?
(and any constructive ideas how to change legalization of CPMs to CMs in already legal states would be interesting as well)
From Alexis:
Yehudit, I was assuming that the MW was already doing EFM for some reason, not that she was planning to delay transfer for it. But anyway, my point was more to answer Susanne's objection about why the hospitals wouldn't cooperate, rather than why the MW would want to do it in the first place.
Jolene, some states license naturopaths and other quacks. Legislators are, by and large, not medical professionals. It isn't hard to convince them that CPMs are qualified. Hospitals accept transfers because their responsibility is to the patient.
The requirements are not the same for CNMs and DEMs and I'm puzzled as to how you think this is the case.
The CM is a nonstarter because it uses the AMCB exam, not the NARM. The usual preparation for the CM is the same program a CNM does. This is unacceptable to NARM. They don't want university or hospital based training.
From Jolene:
"The requirements are not the same for CNMs and DEMs and I'm puzzled as to how you think this is the case."
I am refering to their restrictions and requirements by the state. Not their credential (schooling) requirements.
For instance, CNMs may conduct VBACs at home, so may DEMs. Both CNMs and DEMs are required by state protocal to recommend transfer when X occurs. (and nobody can "force" a woman to transfer, just so you know where the word recommend comes from)
Back to my example above, while many consider VBACs unsafe at home when conducted by DEMs, CNMs are not lobbying to restrict DEMs from conducting VBACs at home, because CNMs want the option of offering VBACs at home as well. Since the state restrictions apply to both types of midwives, they would be restricting themselves at the same time.
Understand now?
"Legislators are, by and large, not medical professionals. It isn't hard to convince them that CPMs are qualified."
How do you plan to counter this in NY when (and it is WHEN) CPMs again lobby for licensure there?
How about licensing them under the MEDICAL board rather than a separate midwifery board?
From Caryn:
How about licensing them under the MEDICAL board rather than a separate midwifery board?
Works for me. But you'll hear from plenty of nurses and midwives insisting that midwifery isn't medical care.
From Susanne:
"For instance, CNMs may conduct VBACs at home, so may DEMs. Both CNMs and DEMs are required by state protocal to recommend transfer when X occurs."
Many DEM's don't WANT to practice in a system where they would be required to transfer (or strongly recommend transfer) when X occurs. Because that involves oversight, and they don't want oversight. They want to be free as a bird in their practice, except when all hell breaks loose and then they insist that the medical profession that they otherwise distrust be there to save them.
Let's face it, most of these women are just birth junkies, who want a little more excitement than being a doula but don't want to put in the hard work of being a CNM.
From Alexis:
Actually, in most CPM-legal states, they do NOT have the same restrictions: CNMs are often required to have written practice agreements and CPMs are not.
Caryn, in NYS, all midwives are governed by a board of midwifery. The nurses and midwives do have a point: nursing and midwifery are not medicine, and need their own regulations and board(s). MDs are not the sole arbiters of health care.
I do not think CPMs will be legalized in NYS. It's not a priority for them. CPMs CAN become licensed here, if they meet the additional requirements of the law and find a backup OB. I do not think CNMs would be happy if CPMs were permitted to go without practice agreements when they are not. (Many CNMs are not happy about the law anyway and want to change it to requirements for consult, rather than a formal agreement.)
Further, it's much easier to counter the argument when we do have a procedure for non-nurse midwives to become licensed--it will look as if DEM advocates only want to relax the requirements.
From Jolene:
"Many DEM's don't WANT to practice in a system where they would be required to transfer (or strongly recommend transfer) when X occurs. Because that involves oversight, and they don't want oversight. They want to be free as a bird in their practice, except when all hell breaks loose and then they insist that the medical profession that they otherwise distrust be there to save them."
This may be true. But when they are legalized and licensed with regulations like any other midwife (CNM) they must have the same oversight. I didn't realize that DEMs were lobbying for licensing while at the same time insisting on no oversight? Can you show that they are? It sounds like not too serious bitching and moaning to me. Who WOULDN'T want to be free as a bird with no oversight?
"Further, it's much easier to counter the argument when we do have a procedure for non-nurse midwives to become licensed--it will look as if DEM advocates only want to relax the requirements."
True. Good point. Do you think if CNMs are successful in changing the language to "consult" rather than supervisory, DEMs will want to come in at that point?
From Caryn:
The nurses and midwives do have a point: nursing and midwifery are not medicine, and need their own regulations and board(s).
I remain unconvinced. 
All I can find is an *assertion* that nursing and midwifery are not the practice of medical care. But: why not?
Granted: they're not practicing exactly the same set of medical services that doctors provide. But doctors don't provide exactly the same set of medical services as each other, either.
And if it's not medicine that they're doing, what *is* it that they're doing when OBs attend a perfectly normal birth that doesn't require any form of medical supervision? Nursing? Midwifery?
From Yehudit:
when OBs attend a perfectly normal birth that doesn't require any form of medical supervision?
+++++++++++
They are doing midwifery. That is what my grandfather described himself doing as a family doctor in the 1930s/40s (before he specialized in paediatrics). E.g. "I did quite a bit of midwifery in those days..."
From Liz:
Interesting, but probably not all that easy, if one COULD differentiate, or allocate a strict definition to the terms nursing, midwifery, medical. I doubt very much whether there is a real, clear, covers all eventualities definition.
Yehudit, your grandfather may well have considered himself to have been doing midwifery when he was present at a normal, straightforward birth - but presumably he had the ability to move swiftly into medical mode if an emergency occurred. It is the midwives who can't or won't that worry me.
From Alexis:
Caryn, "medical care" and "medicine" are not synonymous. The care provided may be medical in nature, depending on the task at hand, but nurses are not doctors, and expecting doctors to oversee nursing as a profession is, at the very least, condescending. As for the OB example: we classify by training and profession, not by task. The delivery of a baby is a specific task which may be carried out by a variety of personnel.
I recall previous conversations where nurses and midwives attempted to convince you that they don't practice medicine, and you kept reducing it to specific tasks performed. Nursing is its own profession.
Jolene, oversight varies a great deal by state. States where midwives are formally licensed usually do have some type of board, but unfortunately, the current climate of direct entry midwifery is one that emphasizes protecting its own (I've heard some nasty stories from clients about bad midwives who were never talked about). In other states, the board is composed of a variety of health care professionals including CNMs and MDs.
From Caryn:
The care provided may be medical in nature, depending on the task at hand, but nurses are not doctors
But are they providing medical care?
This isn't just a semantics argument. If you want, you can say that, by definition, care doesn't count as medical care unless it's given by a doctor. But the point still stands: nurses are doing things that are similar to the things that doctors do, and that require similar sorts of training, in particular training in the scientific basis of understanding of illness (including acute illness of the sort pregnant women experience) or and how they progress, detecting diseases, and assigning treatments to them *or* knowing when to hand off care to a more specialized provider.
Why isn't that medical care? It's medical care when an internist refers me to a cardiologist because I require the more specialized medical care that the cardiologist can provide. Why isn't it medical care when a midwife refers me to an obstetrician because I require the more specialized medical care that the obstetrician can provide?
I recall previous conversations where nurses and midwives attempted to convince you that they don't practice medicine, and you kept reducing it to specific tasks performed. Nursing is its own profession.
In virtue of being a profession, surely it's entailed that a certain set of tasks are one's professional responsibility, and a certain set of practices are used to achieve the eventual goals of the profession. Presumably being a member of the profession precludes the performance of other tasks or actions, like those that are in conflict with the goal of the profession. Being a responsible nurse (or doctor) entails not setting a patient on fire. Maybe we can't class things *in*, but we can certainly class things *out*. Negation is the origin of content.
As I said, I remain unconvinced. Again, this is merely an assertion on your part that nursing is not medicine or medical care but shares some responsibilities with doctors who are practicing medicine; no one's said what it is that nursing consists of (or *doesn't* consist of), how it is different in kind from what it is that doctors do, and so forth. If I recall correctly, I was informed that it was "an important and difficult question", which doesn't answer it.
(This is why I'm currently working working my way through four nursing theory texts, all of which are distressingly incoherent and none of which answer the question either.)
Nursing can be its own profession *even if* it is not different in kind from what it is that doctors are doing. Oncology is a different profession from obstetrics.
From Caryn:
Interesting, but probably not all that easy, if one COULD differentiate, or allocate a strict definition to the terms nursing, midwifery, medical. I doubt very much whether there is a real, clear, covers all eventualities definition.
Not yet.
From Caryn:
They are doing midwifery.
At what point do the responsibilities of the OB differ from the responsibilities of a midwife? At what point is the OB not doing her job, but the midwife is still doing hers?
From Alexis:
Caryn, I'm not saying that the care is inherently different if it's provided by a nurse or a doctor. But we're speaking in the context of professional regulation here, and the professions in general, not about whether doctors and nurses sometimes perform the same tasks. Both professions draw on the same base of medical knowledge, and many of the tasks performed are the same (an IV is an IV, et cetera).
You said it "works for you" that midwives be regulated by the medical board. It doesn't work for me, because nurses (and midwives) are not doctors, and why should the medical board (which regulates doctors) be regulating other professions? Unless you're just going to lump all kinds of healthcare providers in together, which would solve the problem of differentiation but be a logistical nightmare.
From Caryn:
You said it "works for you" that midwives be regulated by the medical board. It doesn't work for me, because nurses (and midwives) are not doctors, and why should the medical board (which regulates doctors) be regulating other professions?
Why shouldn't medical professionals be regulated by the medical board?
Think of the oncologist/obstetrician example. Why aren't nursing and midwifery medical professions?
From Alexis:
Because the "medical board" doesn't just mean health related professions; it means doctors. As I said, putting doctors in formal charge of nurses is, at the very least, deeply condescending.
As I said, if you want to propose some kind of unified oversight board for health professions that would be composed of various sub-disciplines (medicine, nursing, midwifery, PAs, what have you) that would be different, though logistically I'm not sure it would work. But as it stands, the medical board relates to the practice of medicine, i.e. MDs and DOs.
From Caryn:
if you want to propose some kind of unified oversight board for health professions that would be composed of various sub-disciplines (medicine, nursing, midwifery, PAs, what have you) that would be different, though logistically I'm not sure it would work.
It seems to me that what the state is interested in here is how medical care is provided. Midwives might well want to have additional requirements about how midwifery care is provided, but the part the state cares about is the medical outcome.
From Alexis:
How professions are regulated is not solely a question of state interests, though. It's heavily influenced by the interests and beliefs of the professions themselves, and that's not unique to midwifery.
From Caryn:
How professions are regulated is not solely a question of state interests, though. It's heavily influenced by the interests and beliefs of the professions themselves, and that's not unique to midwifery.
Certainly. There are some professions the state has no legitimate interest in (the state doesn't regulate philosophers, for example.) There are also professions where the state has at least a partial interest. That doesn't mean that there aren't additional components of care that the state isn't interested in mandating but the profession *is* interested in mandating. (As I understand it the AMA forbids all sorts of stuff that's not illegal, but the state doesn't care about that when it's time to get a medical license.)
I am claiming that the state is interested in regulating the medical care components of any profession. And in this case, the people who know the most *about* the necessary medical care are the ones you'd ask.
I don't see that it's condescending to suggest that where the responsibilities of nurses overlap with medical care per se, that the people who *know the most about the way the world is in this respect* are the ones who set the guidelines.
The doctors on medical oversight boards aren't taking orders from other doctors wrt the medical care that leads to the lowest morbidity and mortality. They're taking orders from external reality.
Whatever midwives want to add as additional components of regulation of their discipline cannot conflict with what it is that we know about the natural world. And the people you'd go and ask about that would be people who were specialists in providing medical care for the sorts of acute illnesses midwives might need to manage. Like medical researchers or MFMs.
From Susanne:
"Why isn't that medical care? It's medical care when an internist refers me to a cardiologist because I require the more specialized medical care that the cardiologist can provide. Why isn't it medical care when a midwife refers me to an obstetrician because I require the more specialized medical care that the obstetrician can provide?"
Bingo.
From Alexis:
Caryn, asking a doctor for an opinion on a particular case--which a nursing or midwifery board might well do--is not the same thing as putting nurses/midwives under the general responsibility of doctors, which is what subsuming their regulation under the medical board would do. It is condescending to do that because it suggests that nurses can't self-regulate. In addition, there's a lengthy history of tension between medicine and nursing. You'd never get nurses (or midwives) to accept the regulatory superiority of MDs.
From Caryn:
putting nurses/midwives under the general responsibility of doctors, which is what subsuming their regulation under the medical board would do.
It would put the *medical care portion* of what they do under the supervision of the experts in medical care.
It is condescending to do that because it suggests that nurses can't self-regulate.
Given that we *know* that NARM is certifying DEMs over their understanding of a falsified theory of preeclampsia, it seems reasonable to me to conclude that DEMs cannot self-regulate in a fashion the state can accept.
CNMs as a group might want to decide what they'd like to do about an affiliation with DEMs here, and might question what it is that counts as a midwife.
From Jolene:
"Given that we *know* that NARM is certifying DEMs over their understanding of a falsified theory of preeclampsia, it seems reasonable to me to conclude that DEMs cannot self-regulate in a fashion the state can accept."
The problem with this is that the state (many) has accepted it.
Do you have any ideas of what can be done about the faulty understanding of pre-e by DEMs? And is it only DEMs that subscribe to this theory or are there other accepted/integrated groups (at least in some stated) who do so as well that we could refer to collectively?
From Susanne:
It's funny how physical therapists, occupational therapists, etc. don't seem to have these "problems." Funny how they don't have to have hissy fits over Making Sure Everyone Knows Their Very Important Roles.
From Caryn:
The problem with this is that the state (many) has accepted it.
Sure. People make mistakes in the short run. The advantage of the scientific method and democracy in general is the potential for correction.
Do you have any ideas of what can be done about the faulty understanding of pre-e by DEMs? And is it only DEMs that subscribe to this theory or are there other accepted/integrated groups (at least in some stated) who do so as well that we could refer to collectively?
I'm suggesting one idea here; state pressure to amend their licensure exam. That might be driven from the ground up by dissatisfied patients, and it might come from CNMs as a body, and it might come from OBs or MFMs as a body.
Originally Brewer was ignored, on the grounds that the science could speak for itself, and that there was no point in wasting perfectly good resources on rebuttal. Unfortunately, that doesn't work.
This is illustrative, particularly the RNs and BSNs and CNMs and Bradley method educators.
From Ericacrochets:
"Do you have any ideas of what can be done about the faulty understanding of pre-e by DEMs?"
I think the problem is that you cannot believe in what is known about preeclampsia and that "birth is safe" simultaneously. Because it affects at least 5-8% of all pregnancies, many of those "low-risk" first pregnancies. You can't believe that "birth is safe" but know that 1 in 12 mothers is going to have her body basically decide to self destruct because of pregnancy. You have to explain it away somehow, like saying that preeclamptics are malnourished.
If you accept the knowledge that we have about preeclampsia, it forces you to look at pregnancy more as a disease. Especially since that's only ONE THING that go wrong during pregnancy/birth. There's plenty of things left over for the other 92% of pregnancy women.
From Caryn:
It's funny how physical therapists, occupational therapists, etc. don't seem to have these "problems." Funny how they don't have to have hissy fits over Making Sure Everyone Knows Their Very Important Roles.
That might be because they can say, in a sentence or two, what their roles are.
From Susanne:
"Do you have any ideas of what can be done about the faulty understanding of pre-e by DEMs?"
Probably nothing, but that doesn't mean that we have to certify them or accept their ideas as having any validity whatsoever.
And see, Jolene, the DEM movement is all about "I want to have my own pet theories, uninhibited by data, but I also want to be accepted and I want to be recognized as a part of the team on a woman if she needs transport." It doesn't work that way.
DEM's wouldn't hold these theories if they went to real schools with real professors, but you can't make 'em. Well - you *can* make 'em if you make being a CNM the requirement to attend homebirths legally.
From Susanne:
And Jolene, no, no one subscribes to their "theory of preeclampsia" other than them. No one reputable in the field, that's for sure.
(But what difference would it make if more people subscribed to it? More people subscribing to faulty theories doesn't make the faulty theory more correct.)
From Susanne:
"Do you have any ideas of what can be done about the faulty understanding of pre-e by DEMs?"
Why don't the DEM's take it upon themselves to review and revise their own faulty thinking? Why do they have to be led to it by other people? It reinforces the can't-hack-it crowd.
From Susanne:
"You can't believe that "birth is safe" but know that 1 in 12 mothers is going to have her body basically decide to self destruct because of pregnancy. You have to explain it away somehow, like saying that preeclamptics are malnourished."
Right. So what do you do? You don't learn *real* biology and chemistry - you learn a watered-down version that wouldn't even pass muster as an AP Biology or AP Chemistry high school course. You learn about flowers and homeopathy and affirmations and thinking lovely thoughts. And you restrict your experience to looking only at women who are healthy in the first place and then sending them away if they turn south. Congrats, you're a DEM!
From Caryn:
Why don't the DEM's take it upon themselves to review and revise their own faulty thinking?
Because they can't self-regulate.
From Susanne:
I understand; it was more a rhetorical question!
From Caryn:
I know.
Seriously, though, let's define self-regulate here. Surely it includes the idea that the profession doesn't shoot itself in the foot.
From Susanne:
I may not articulate this clearly, but bear with me. Part of self-regulating may include the idea of coordinating with other specialties; that is, if there is a research question about a cardiology problem in pregnancy, the OB community and the cardiology community will research, publish, cross-share findings. And they are working off a common scientific basis of understanding the world, conducting research, how insights are gained, etc. Ditto for the physical therapist working with the rehabilitation doctor. Etc.
And yet DEM's are on their own tiny little island, without any collegial relationships as a specialty with anyone else. Why is that? Why do THEY think no one takes them seriously?
From Jen:
"Why do THEY think no one takes them seriously?"
Because they are the ones who know The One True Way (TM) and the medical world is desperately trying to marginalize and discredit them because they know that once women know The Truth, all women will shun the medical model and flee to the midwives, leaving the poor OB's and Hospitals broke and desolate. Didn't you know that? @@
From Holly:
Oooo....Were we talking about licensing CPMs in NC? Yes, the bill will pass; I am confident of it. Licensing CPMs is a part of a larger agenda on the part of advanced practice nurses. License CPMs, make CNMs autonomous, make NP's autonomous. We have had extensive discussions about it in my nursing lectures. There are many, many people behind this bill, and they aren't all homebirth hippies. Some don't even care one way or the other about homebirth. This bill is about a lot more than licensing CPMs.
From Caryn:
Holly, given that CPMs credentialling is based on understanding of a falsified theory of preeclampsia, why shouldn't the state be in a position to require them to change their licensing exam?
From Jolene:
"Holly, given that CPMs credentialling is based on understanding of a falsified theory of preeclampsia, why shouldn't the state be in a position to require them to change their licensing exam?"
This is an excellent idea, and one I think has a chance of actually going somewhere.
"I may not articulate this clearly, but bear with me. Part of self-regulating may include the idea of coordinating with other specialties; that is, if there is a research question about a cardiology problem in pregnancy, the OB community and the cardiology community will research, publish, cross-share findings. And they are working off a common scientific basis of understanding the world, conducting research, how insights are gained, etc. Ditto for the physical therapist working with the rehabilitation doctor. Etc."
It's funny you use this exact example Susanne. My husband works in cardiology, 2 years ago he was invited to present on a specific cardio complication of pregnancy..... wait for it.... to a group of midwives (a DEM run group who also host CNMs at their local meetings) He ended up declining for technical reasons. Now this wasn't the type of sharing you are talking about. But it's certainly a step forward. And this kind of reality doesn't jive with your world view of DEMs.
From Holly:
I'm sorry, what? I have never studied to be a CPM, so I am not aware of what they require so far as pre-e is concerned. I know CNMs are taught the facts about pre-e (that it essentially has no risk factors, the only cure is delivery of the baby, s/sx of eclampsia, mgso4, etc). But, it seems to me that if the state were to license CPMs, they would have the power to regulate them (including significant pull in regards to licensing exams).
I don't think that current CPM education is as good as homebirth midwifery can get. However, no one has come up with a better way of doing things unless you want to make CNMs autonomous. No one likes that idea either, so it seems that we're in a game of chicken. The medical board is saying "let them eat cake". I don't find that sufficient and obviously neither did the legislative study committee.
My primary dog in this fight used to be that I had a homebirth and I have friends who are homebirth midwives. While that's still a big concern of mine, as a future CNM, now my main goal is CNM autonomy (just like my FNP friend's reason for supporting this bill is FNP autonomy). Licensing CPMs is going to make/help that happen.
From Caryn:
Holly, the NARM exam relies on the Brewer Diet.
If CNMs are allying themselves with a subset of the midwifery profession that rejects modern science, particularly in a way that directly impacts patient morbidity and mortality, why shouldn't the state restrict their autonomy?
From Holly:
It's political, Caryn. It's not about birth philosophy. It's beneficial on the part of CNMs to support this bill. I'm sure you understand how these things work.
From Holly:
CNMs and CPMs don't agree on everything philosophy-wise, but the ACNM is in support of homebirth, so there is common ground.
From Caryn:
Here's the thing, though: Brewer isn't a philosophy. It's a theory. It's testable. It makes empirical predictions. It's not even close to the current understanding of the problem, and it cannot handle huge subsets of the data surrounding preeclampsia.
If DEMs aren't using science to make decisions about care, they're going to provide *worse care* than other practitioners. This might well provoke the state into restricting their autonomy. If CNMs are allied with them, the CNMs are tainted by association; they've failed to argue against poor practice and put their own interests ahead of the interests of their clients. That's poor care.
From Alexis:
Holly, how does licensing CPMs fit into the fight for increased autonomy for APNs? It seems to me that's a straight up fight between the AMA and the nursing associations.
From Caryn:
And when I say: put their own interests ahead of the interests of their clients, I'd like you to consider this: what makes a midwife? Who counts as a midwife? In particular, why is what the DEMs are doing here *not midwifery*?
From Caryn:
darn it, edit fail
When I say put their own interests ahead of their clients', I'd like you to consider this in your answer: what makes a midwife? Who counts as a midwife? In particular, why is what the DEMs are doing here *not midwifery*?
From Holly:
Alexis, It has been explained to me like this:
If the state licenses CPMs to provide autonomous midwifery care to women, it wouldn't make sense for the state to not allow CNMs to provide that same care to women autonomously. If CNMs can provide autonomous care, other advanced practice nurses must be able to as well. That's why APN's are backing this bill. (And by APN's, I mean the APN's at ECU, which is the only university in NC that offers a CNM program. The director of the program as well as another professor in the midwifery program both spoke very much in favor of the bill during the legislative committee meetings.)
From Holly:
Does the Brewer diet hurt anyone? Unless it's denying women care for their pre-e (and I'm sure any licensing guidelines are going to risk out women with high blood pressures so CPMs wouldn't even be treating pre-e theoretically) extra protein in a woman's diet isn't hurting anything in a healthy woman.
From Holly:
Caryn,
I do think DEMs practice midwifery. It's lay midwifery, but it's midwifery.
There is a gap here in patient care. You have a woman who is going to have a home birth. She just is. If you don't provide a legal HCP for this woman, she's going to birth by herself in her bathtub. This woman is not going to go to the hospital. What are YOU going to do for this woman? Does this woman deserve care at all? Does she deserve care from a legal practitioner licensed and regulated by the state? Does she deserve a method for recourse in the event of a catastrophe?
Here is the disconnect. What are you going to do for this woman? What are her choices? Birth at home by herself or birth against her will in a hospital. Those aren't very many choices. In the interests of good patient care, legal, licensed and regulated practitioners need to be available to this woman in her home to help her give birth. I'm not talking crazy talk here. I do think I might be living on the wrong side of the ocean.
Home birth is a safe (relatively) and cost-effective way for managing low-risk women. Is the mortality/morbidity rate higher? Probably. Do that many people die in home birth? I don't think so. I guess we'll see when the statistics in the UK come out, but I don't think somewhere like the UK would allow home birth if it wasn't a decision based on a positive cost-benefit analysis.
From Caryn:
Does the Brewer diet hurt anyone?
Yes. Women don't transfer care because the problem is their diet, and they can fix it by changing their diets.
The licensing guidelines in Texas simply require transfer of care when it is customary for other midwives to transfer care, rather than placing legal requirements for transfer in place. Since it isn't necessarily customary for midwives who accept the Brewer theory to transfer care of their clients, it's entirely possible for women to remain with a care provider who's not equipped to manage that sort of acute illness.
And kidney sparing diets are generally low-protein; there's at least theoretical reason to think adding additional protein to the diet of a woman with compromised kidneys merely compromises them further.
Wholly aside from those points, it is *failure to provide standard of care* that I'm referring to.
From Holly:
Well, a woman in renal failure or a woman with pre-e is no longer a low-risk client. In a low-risk client with no comorbidities, Brewer's diet does not hurt anyone. If the licensing guidelines do not specify when a woman should be transferred out (elevated blood pressure) then I think those guidelines should be in place. But I don't think lack of those guidelines should restrict licensing of all CPMs. Instead I think those guidelines should be instated and CPMs still licensed.
From Caryn:
I do think DEMs practice midwifery. It's lay midwifery, but it's midwifery.
What's the difference?
Does this woman deserve care at all? Does she deserve care from a legal practitioner licensed and regulated by the state?
Can individuals dictate the sort of care that they receive from health care providers? Can they require that the state provide them the form of care that they want?
From Caryn:
But I don't think lack of those guidelines should restrict licensing of all CPMs. Instead I think those guidelines should be instated and CPMs still licensed.
Why shouldn't CPMs be required to learn the current science underpinning our understanding of preeclampsia, instead of a falsified theory? At the moment, they're learning something equivalent to geocentrism.
Should the state be licensing people to diagnose and transfer acute medical crises if they don't have a modern understanding of the mechanism underlying these conditions? This isn't just something that people believe with no consequences; this is something people believe that affects their ability to provide care for a condition that causes substantial morbidity and mortality, and is therefore something in which the state has a substantial interest.
From Alexis:
Caryn, Texas does not require transfer at all. It requires discussion and note for all antepartum problems.
Holly, I don't think CPMs will achieve anything for APNs. Quite a few states have the anomaly now whereby CNMs require supervision or backup and CPMs don't and there's little move to fix that. Furthermore, the numbers of CPMs are very limited and always will be since home birth is and will be a fringe movement. APNs are most assuredly NOT fringe. (Ditto PAs, who also require supervision of some type.) The AMA will fight for retention of supervisory arrangements for APNs much more aggressively and allowing CNM full autonomy would mean allowing it for tens of thousands of APNs. This is something the AMA will not allow if they have any say in it.
As for the UK, bad example. One, it's heavily political. Home birth allows the illusion of choice. In practice, by the way, home birth will not be expanded greatly because they refuse to fund the necessary midwives to make it possible. Two, NHS midwives work in an entirely different context.
We've been through this before, but the state is under no obligation to provide a legal provider simply because someone wants it and won't use the available alternatives. What happens if CNMs can provide home birth but people don't want to use them because they're too medical? I've heard from MDCers who ONLY want to use unlicensed midwives.
From Holly:
No one is requiring the state to do anything against their will. Legislators are responding to the needs and requests of those who elected them into their positions. And then those legislators are voting in favor of those proposals. This is a democratic process. The state is choosing to license these practitioners, and for the reasons I mentioned. Obviously the state sees a need and is responding to it accordingly. Why don't you see that need? Why don't you think those women deserve care, even if the state democratically decides to provide that care?
From Caryn:
Legislators are responding to the needs and requests of those who elected them into their positions. And then those legislators are voting in favor of those proposals. This is a democratic process.
You can't vote to change scientific reality. And any time you try, it doesn't work.
Why don't you think those women deserve care, even if the state democratically decides to provide that care?
I don't think those women deserve substandard care. I think voting to give women substandard care is appallingly shortsighted.
From Caryn:
Caryn, Texas does not require transfer at all. It requires discussion and note for all antepartum problems.
Ah, even worse.
From Holly:
Well, then I disagree with you on two points. I do think licensing CPMs will affect CNM autonomy. And I think that home birth in the UK is about cost-benefit analysis. I think the UK has decided that the number of people dead or harmed by home birth (few) is worth the cost savings. Right now I agree with them. We will see when the statistics surface and we can get an accurate idea of the impact of home birth on morbidity and mortality rates.
From Caryn:
Holly, what's the difference between the training a lay midwife gets, and the training a midwife gets? Who counts as a midwife, and why?
From Holly:
But Caryn, this isn't about science. It's about politics. If you don't agree with it, take it up with your politician. A politicians job is to listen to his/her constituents. The recommendation by the study committee in NC is a perfect example of the power of lobbying. I was there for three out of the four legislative study committee meetings. They were packed with baby-wearing and breastfeeding women. So were the fundraisers. We were present, we were loud and we caused a fuss. Where was the opposition? A politician's job is to listen to their people and vote according to how those people want them to vote. A politician's job isn't to sit around and read scientific journals.
From Caryn:
I think the UK has decided that the number of people dead or harmed by home birth (few) is worth the cost savings. Right now I agree with them.
I'd be more reassured that patients would be transferred as necessary if a modern understanding were in play. My state-certified midwife looked at my 130/80 (up from 90/60) and my trace dip and said, eat more protein, see ya in 2 weeks. By then my baby was out of NICU; a week after that appointment, I transferred care at +17,000 mg/24 hours and a bp of 220/116.
People can vote for my baby and me to get substandard care, but is it right for them to do so?
From Holly:
Both "count" as midwives. In a perfect world all midwives would graduate from a formal training program approved by the ACNM (not necessarily a master's program, but some type of comparable training). But we don't live in a perfect world. CNMs can't meet the demands of homebirthing women. So these other midwives have sprung up to fill in the gaps. Until CNMs can meet all of the demands of homebirthing women, these other midwives will be necessary to provide care where there otherwise would be no care in patients who are hellbent to homebirth.
From Caryn:
A politician's job is to listen to their people and vote according to how those people want them to vote. A politician's job isn't to sit around and read scientific journals.
That's otherwise known as "tyranny of the majority."
From Caryn:
Both "count" as midwives.
Why?
From Holly:
Or democracy.
From Holly:
Both count as midwives because there is no national standard for what constitutes a midwife. Even the ACNM recognizes lay midwives as midwives.
From Susanne:
"Does the Brewer diet hurt anyone? Unless it's denying women care for their pre-e (and I'm sure any licensing guidelines are going to risk out women with high blood pressures so CPMs wouldn't even be treating pre-e theoretically) extra protein in a woman's diet isn't hurting anything in a healthy woman."
Shame on you, Holly. It most certainly does, because it means that women showing signs/symptoms are being "treated" by go-eat-some-more-eggs, which has zero scientific basis, instead of being referred out post-haste. And you think the good people of NC should be allowed to have people like THAT practice on and care for them?
From Caryn:
Or democracy.
Holly, this is why judges overturn legislative decisions. I'm not surprised to hear that a CNM student is happy to violate my rights, but it certainly doesn't make me inclined to support your agenda.
From Holly:
Brewer's diet does not hurt low-risk women without pre-e, renal failure, etc., Susanne. In women without complications, a higher protein diet is not harmful (other than possible constipation).
From Caryn:
Both count as midwives because there is no national standard for what constitutes a midwife.
And you don't see this as a problem? You're not worried that the standards of your profession will be so watered-down as to be eliminated? You're not afraid that in supporting midwives, you'll find yourself supporting flagrantly immoral positions?
From Susanne:
"There is a gap here in patient care. You have a woman who is going to have a home birth. She just is. If you don't provide a legal HCP for this woman, she's going to birth by herself in her bathtub. This woman is not going to go to the hospital. What are YOU going to do for this woman? Does this woman deserve care at all? Does she deserve care from a legal practitioner licensed and regulated by the state?"
Yes, but the state has every right to determine what the licensing and regulating is. And they don't have to accept substandard crap like the NARM licensing exam, with its false theories of pre-e, just cause some women want a homebirth reaaaaalllllly bad and they're going to do it anyway.
From Caryn:
Brewer's diet does not hurt low-risk women without pre-e, renal failure, etc.,
But how do you tell which women are low-risk, and which women are going to develop medical complications?
From Susanne:
"If you don't provide a legal HCP for this woman, she's going to birth by herself in her bathtub. This woman is not going to go to the hospital. What are YOU going to do for this woman? Does this woman deserve care at all?"
So, I'm entitled to demand that because I don't want to go to the dentist but I'd rather have my teeth pulled in the comfort of my own home, that the state should license my next door neighbor as a dentist? That's essentially what you're arguing, Holly.
From Holly:
Because you take their blood pressure! That's part of monitoring- taking bp's. BP is elevated, with greater than +1 in urine, that's a problem.
I've got to go to bed. Clinical starts at 6 am and I'm on the east coast.
From Holly:
If there are enough of you to demand that they license home dentists, susanne, and you cause enough of a stink, and get enough politicians on your side, then yes, I suppose it should be put up for a vote. Look, CPMs are just utilizing the democratic process. Why don't you? Write your legislators about it. This is how the process works.
From Caryn:
Because you take their blood pressure! That's part of monitoring- taking bp's. BP is elevated, with greater than +1 in urine, that's a problem.
At my 32 week appointment, my state-certified midwife took my bp at 130/80 and my trace dip, and said, see you in two more weeks, eat some protein.
And then she left.
From Susanne:
"So these other midwives have sprung up to fill in the gaps. Until CNMs can meet all of the demands of homebirthing women, these other midwives will be necessary to provide care where there otherwise would be no care in patients who are hellbent to homebirth."
No, they aren't "necessary." Dentists don't want to come to my house and pull my tooth while I'm sitting on my front porch, but that doesn't obligate the state to license a second, inferior class of faux-dentists to satisfy my "need."
It is not as though there is no care. Some women just don't like it. That's hardly a "need." No woman has a "need" to homebirth, any more than I have a "need" to have my dental care take place in my home. Stop equating preferences and desires with needs.
From Susanne:
"Because you take their blood pressure! That's part of monitoring- taking bp's. BP is elevated, with greater than +1 in urine, that's a problem."
Newsflash, Holly: For some of us who had HELLP, myself included, we didn't have blood pressure spikes. Your understanding of the syndrome is quite limited.
From Caryn:
Look, CPMs are just utilizing the democratic process. Why don't you? Write your legislators about it. This is how the process works.
Part of the process involves convincing legislatures that their constituents are asking for unreasonable things. That's the job of the people who understand science. You can't vote reality away, and this isn't a power grab; doctors take orders from reality too.
This path is only going to get CNMs placed under the oversight of doctors. It's a lousy strategy.
From Caryn:
And wholly apart from strategic concerns (and I'm assuming you're not *only* interested in maximizing your own interests here, but actually think that women deserve care), this strategy leads to a horrible outcome.
Licensing care providers who don't know what they're doing is the same thing as legalizing quacks.
From Susanne:
Aww, you're going to hurt their widdle feelings by calling them quacks! They are Empowered Wise Women, and they can just "feel" who is going to become pre-eclamptic and who isn't!
And yes, I'm being snarky, Holly. Because this isn't a freakin' game. Because women deserve better than to have the legislature blow sunshine up their asses because they "want" substandard providers.
From Caryn:
Aww, you're going to hurt their widdle feelings by calling them quacks!
As I said above, if you water down the standards of the profession far enough, you *eliminate* the standards of the profession.
This is precisely why it matters what it is that counts as the role of a midwife, and where the line is between midwifery, and something else.
From Liz:
When it comes to cost-benefit analysis, a simple fact is that in England, dead babies are cheap. And damaged babies born at home are probably cheaper too, as litigation would be a lot more difficult.
It is illogical to say: "some women are dead set on staying out of the hospital, so you have to provide them with care" if the care you are providing them with can be sub-standard.
And what makes pre-e so hard to deal with is its insidiousness. It's hard enough to get highly trained doctors to react appropriately, never mind people who think boiled egss will fix it.
From Yehudit:
I don't think the actions of any doctor or midwife in the UK is driven by the idea that 'dead babies are cheap.' A dead baby is about the worst thing (other than maternal death) that can happen in a maternity unit and ensuring the safety of women and their babies is the primary purpose of routine antenatal care, referral, specialist clinics, assessment units, etc...
Yes, sometimes people make different clinical judgments. These are based on clinical arguments about when is best to intervene from point of view of mother and baby, the balance of risks and benefits, and the interests of the many vs. the few. But no one thinks "Oh well, babies are cheap so I'm not too bothered if one dies on my watch."
From Mama Liberty:
"Part of the process involves convincing legislatures that their constituents are asking for unreasonable things. That's the job of the people who understand science."
Wow, I think I should re-read the Constitution. I didn't realize that the federal government (or any state government) is to fill the role of distinguishing reasonable from unreasonable or that people who understand science are given special ruling authority.
We don't receive our rights from government.
From Susanne:
"Wow, I think I should re-read the Constitution. I didn't realize that the federal government (or any state government) is to fill the role of distinguishing reasonable from unreasonable or that people who understand science are given special ruling authority."
IYO, Mama Liberty, does the govt have or not have the right to license those who provide medical care and ensure they meet certain standards? Are you OK with a society in which Random Joe hangs out his shingle to become a surgeon without any oversight?
From Caryn:
I didn't realize that the federal government (or any state government) is to fill the role of distinguishing reasonable from unreasonable or that people who understand science are given special ruling authority.
Reality has special ruling authority, Mama Liberty.
From Caryn:
These are based on clinical arguments about when is best to intervene from point of view of mother and baby, the balance of risks and benefits, and the interests of the many vs. the few.
Or apparently, sometimes, they're based on false theories instead of clinical arguments. And we can vote to make that okay!
From Alexis:
Holly, home birth is not much cheaper, if at all. In a home birth, you have 1:1 coverage, 2:1 at the end. In a hospital, 1 midwife covers multiple patients until they're ready to push. Home birth is only cheaper than hospital if you have equal staffing levels. (And, since the capital costs of building all the hospitals are already there and will always be--you can't count them towards the "extra cost" of hospital birth.)
The government actually came out and admitted that they could not and would not fund the extra midwives needed for a substantial rise in the home birth rate. For them, home birth was not cheaper: it was too expensive. This was a political dodge aimed to make it look as if women had more choices while they closed and consolidated maternity units.
If NICE says something, it's about money. If the government says it--it's a little bit of money and a lot of politics.
From Liz:
Yehudit, I wasn't suggesting that doctors or midwives calculate that a dead baby is cheaper, simply stating it as fact that is relevant to a strictly cost/benefit analysis. In the same way that even the most ardent homebirth advocate acknowledges that a small number of babies will die, and sees this as a small matter compared with a larger number being free to choose.
From Yehudit:
These are based on clinical arguments about when is best to intervene from point of view of mother and baby, the balance of risks and benefits, and the interests of the many vs. the few.
Or apparently, sometimes, they're based on false theories instead of clinical arguments. And we can vote to make that okay!
+++++++++++
Liz was talking about the situation in the UK, and I was addressing her point specifically (the notion of the 'cheap dead baby' driving clinical decisions).
I don't think differences in approach between different clinicians (not just interprofessional differences, but also intraprofessional differences) in the UK context are based on false theories (like the Brewer diet, for example).
From Jolene:
I'm out of my depth with this discussion. I have but one point.
"At my 32 week appointment, my state-certified midwife took my bp at 130/80 and my trace dip, and said, see you in two more weeks, eat some protein.
And then she left."
Don't you think that this is exactly the reason midwives should have oversight (licensure) and regulations to follow, as well as legislated methods of transfer/caregivers to transfer TO? (mandated malpractice?)
This midwife you describe would loose her license.
From Yehudit:
Holly, home birth is not much cheaper, if at all. In a home birth, you have 1:1 coverage, 2:1 at the end. In a hospital, 1 midwife covers multiple patients until they're ready to push. Home birth is only cheaper than hospital if you have equal staffing levels. (And, since the capital costs of building all the hospitals are already there and will always be--you can't count them towards the "extra cost" of hospital birth.)
The government actually came out and admitted that they could not and would not fund the extra midwives needed for a substantial rise in the home birth rate. For them, home birth was not cheaper: it was too expensive. This was a political dodge aimed to make it look as if women had more choices while they closed and consolidated maternity units.
If NICE says something, it's about money. If the government says it--it's a little bit of money and a lot of politics.
++++++++++
I don't think that's exactly the argument about cost. Home birth reduces the rate of expensive interventions (such as caesarean)
If someone has a baby at home, she doesn't 'block' a postnatal ward bed - possibly for several days (though she will need more postnatal visits in community). She might avoid an early antenatal admission 'not in established labour' as well.
The costs are not just the direct intrapartum costs.
In a hospital one midwife does NOT cover several patients in active labour until they are ready to push. It is IMPOSSIBLE to look after three women simultaneously in active labour. And any midwife who agrees to do it is putting her registration on the line. Think about it for a minute: FHR every fifteen minutes for one minute after a contraction , documentation of contractions...how can anyone do that for three women at once? And it is not really how maternity services work - despite the fact that midwives are desperately overworked!
If a midwife has to be given three woman to look after (perhaps that is a more frequent London situation) the labour ward coordinator would try to arrange it like this:
One woman already delivered on the previous shift to be transferred to the ward. Simply needs shower, tea and toast, set of obs, sort out paperwork. An auxillary can be used to support the midwife with some of that.
One woman admitted for induction on the delivery unit. Needs assessment, insertion of prostin, trace and bed down for the night.
One woman in early active labour, needing 1-2-1 care (which she is not getting), but hopefully will cope with you flitting in and out to do intermittent monitoring while you sort out your other two ladies. By which time she is probably in strong labour and it is even more inappropriate for you to be looking after anyone else.
If you are making calculations about extending and usage of your existing hospital buildings then you can count some capital costs.
We have moved from a lot of routine inpatient antenatal care, to high volume in a day assessment unit. The DAU uses a lot more midwives, ratio is something like 1:2 women at a time, whereas on the ward it is more 1:16. But the DAU is much cheaper, because throughput is higher. The women come in, have a trace/scan, antenatal check, see doctor, plan made - usually home, more rarely admitted. Rather than having similar care on the ward and waiting all day for the doctors round.
We still have to keep the bricks and mortar of the antenatal ward, but if we didn't have the DAU then we would need a much bigger antenatal ward!
From Caryn:
Don't you think that this is exactly the reason midwives should have oversight (licensure) and regulations to follow, as well as legislated methods of transfer/caregivers to transfer TO? (mandated malpractice?)
This midwife you describe would loose her license.
She *was* state-licensed, in a state that required her to have a backup OB, even. The OB spent quite a while documenting her failure to provide appropriate care.
Let me make a bit more explicit my objection here. A CPM who shares only the Brewer theory with his or her clients, and who does not explain or recommend care according to a modern understanding of the syndrome undercuts the ability of those clients to give informed consent. This compromises their autonomy. Without true beliefs about the syndrome, they cannot make independent choices that protect their interests.
Do CNMs *really* want to ally with those who are failing to get informed consent from their clients? And isn't it completely obvious that licensing CPMs as providers is *not* in the interests of the state?
And what's the dodge? That they're not providing medical care, nor do they diagnose. One might ask how they can tell whether or not someone needs care if they can't diagnose them as pregnant, because it seems like their options then are a) treat everyone, or b) take directive from someone else who *can* diagnose.
From Caryn:
I don't think differences in approach between different clinicians (not just interprofessional differences, but also intraprofessional differences) in the UK context are based on false theories (like the Brewer diet, for example).
I suspect depends on which nursing theory UK providers are operating under, as some of them are transparently false.
There are UK signatories to the Brewer endorsement page that I linked above, but they seem to be primarily doulas and childbirth educators. I applaud UK midwives.
From Susanne:
Can anyone provide a good defense to why DEM's/CPM's shouldn't have to go to CNM programs, that goes beyond "but I don't wannna!" "it costs too much!" and "who will watch my children?", none of which are reasonable objections?
From Holly:
Susanne, I don't give a damn about hurting people's feelings, so call them quacks all you want. It's really just a red herring. The fact is that you *can* legislate who is a licensed care provider and who is not. You don't like it- tough shit. That's the way the system works. You can disagree with the decisions that are made by our legislators, but that doesn't make those decisions legally invalid- merely the fact that you disagree with them. Officials are elected by the people, and then those officials vote on bills that either do or do not become laws. Do I need to pull out my Schoolhouse rock "I'm just a bill on capitol hill?" (Of course this is for the federal, but it works much the same way for the state.) http://www.youtube.com/watch?v=m...h?v=mEJL2Uuv-
oQ
This is the way it works. If you disagree with licensing CPMs, work the system. Stomping your fit in a little hissy fit isn't doing anything other than raising your blood pressure.
From Joy:
Fortunately, it has nothing to do with "I don't wanna" or any of those other phrases that you list. For at least a partial answer, I suggest that you go to the "Inaccuracies" through this link. The inaccuracy that pertains to your question would be second one from the bottom (each one is separated from the next by a blue line).
http://home.mindspring.com/~djsn...jones/
id79.html
Joy
From Alexis:
Yehudit, 1:1 coverage is a pipe dream in London. They most certainly are covering multiple women in active labor. I've heard women be advised to get an epidural simply to get 1:1 coverage--and midwives balking at giving them for the same reason. And since the government admitted that expanding home birth would require hiring many extra midwives that they weren't prepared to fund, I think we can take it as a tacit admission that staffing ratios on the wards are much worse than you'd see at home.
Susanne, there's a perfectly good argument for not requiring that midwives be nurses. It's not necessary and most other countries don't require it. There isn't a good argument for why midwives should be required to have a training program of a level equal to that of CNMs, in terms of classroom teaching, clinical experience, etc. The arguments requiring a master's degree for CNMs are a little iffy and have to do with degree inflation throughout the healthcare professions. (Though the argument does have a point when we say that PTs/OTs have to get a graduate degree; why not midwives? Most of the OTs I know are mothers and they've managed--in fact, it's extremely popular amongst Orthodox women because of the flexibility once you've qualified.) That said, I'm not sure it's possible to fit the requirements in the time for a bachelor's degree. The SUNY Downstate MS Midwifery for non-nurses requires 33 credits of pre-reqs (assuming 3cr per course) and the degree is 59 credits.
From Caryn:
Joy, you and I have been over this in great detail in the past.
As then, I'd now like an explanation from you as to how the Brewer Diet prevents shallow placentation. I'd like an explanation as to how the Brewer diet modifies HLA-C in a woman with nonactivating KIR. I'd like an explanation for why you seem to think that assuming your premise gets you out of the obligation to test this theory properly. And I'd like to know when you're actually going to have some empirical support for this claim.
From Caryn:
There isn't a good argument for why midwives should be required to have a training program of a level equal to that of CNMs, in terms of classroom teaching, clinical experience, etc.
Bingo.
From Caryn:
If you disagree with licensing CPMs, work the system. Stomping your fit in a little hissy fit isn't doing anything other than raising your blood pressure.
Holly, free and open debate *is* working the system. I find it interesting that the only objection to these arguments that you have is to claim that might makes right.
From Susanne:
"Susanne, I don't give a damn about hurting people's feelings, so call them quacks all you want. It's really just a red herring. The fact is that you *can* legislate who is a licensed care provider and who is not. You don't like it- tough shit."
Well duh Holly, where did I ever argue that the state couldn't legislate who is a licensed care provider and who is not?
Where I disagree with you is that you seem to think it's acceptable for a state to license DEM's/CPM's who subscribe to a completely bogus, unscientific theory. Of course the state has the "right" - they can make the license requirements be over 18 and have a pulse for all they like - but you seem not to care that DEM's/CPM's are flawed in their knowledge base.
From Jolene:
"She *was* state-licensed, in a state that required her to have a backup OB, even. The OB spent quite a while documenting her failure to provide appropriate care."
Did you follow the "story" after transfer of care? Do you know if she was diciplined or what? And if she was treated any differently than... say... a doctor who had done the same thing?
There is recourse for dicipline if a midwife is licensed. None if she isn't.
From Alexis:
Er, that should, of course, read that there isn't a good argument for why non-nurse midwives shouldn't be required to have a program equal in content, etc.
From Jolene:
"Er, that should, of course, read that there isn't a good argument for why non-nurse midwives shouldn't be required to have a program equal in content, etc."
I agree with that! How could the states and ACNM be encouraged to expand the CM credential outside of NY?
From Alexis:
ACNM is open to it, as far as I know. But no one advocates for it. It's the bastard stepchild credential. It doesn't come under the purview of the Board of Nursing, and the DEMs are completely uninterested in it because it's basically the same training CNMs get (Downstate trains CNMs and CMs together and the non-nurses do additional coursework). Only one place offers the program, and few people are rushing to do it when 1) it's only recognized in 3 states (RI and NJ recognize it as well) and 2) for an extra year, you can do BA-to-CNM (or dual CNM/WHNP in case you want to go to a state where NPs have privileges CNMs don't) and be legal in 50. It doesn't appeal to the wannabe DEMs at all.
From Caryn:
Er, that should, of course, read that there isn't a good argument for why non-nurse midwives shouldn't be required to have a program equal in content, etc.
Hah, I read that in from context.
From Caryn:
There is recourse for dicipline if a midwife is licensed. None if she isn't.
Sure. But why should a state grant a license to a person with such a knowledge base in the first place?
From JZ:
I like to get on here every once in a while just to read everyone's bitch session and get a good laugh. The number of states legalizing CPM's is rising and it is totally KILLING you guys and I LOVE IT!!!!
From Susanne:
What added-value you bring, JZ!
From JZ:
Thank you, thank you very much...you've added value to my day by bringing a very big smile to my face!
From Liz:
It is really unlikely to kill "us guys", JZ. The odd baby, perhaps.
From Jen:
""The Certified Professional Midwives' credentialing process was evaluated by independent researchers at Ohio State University as a credential that exemplified the established standards for educational and psychological testing, as determined by the American Educational Research Association, American Psychological Association, and the National Council of Measurement in Education". "
Ya know, if that's true, I'm a little ashamed of OSU (I'm an Ohioan, lol).
However, I wonder a little...does this sentence mean that the certification requirements were evaluated against current scientific and medical understandings and research? Or does this sentence just mean that they evaluated the process and verified that it tested the subject matter well, without any evaluation of what they are taught? (I hope that makes sense). I just can't see how anyone with any scientific background could see what they are taught (including the Brewer Diet) and give it a stamp of approval...
From Alexis:
JZ, the smile may be wiped off your face. With licensing comes scrutiny and responsibility. CPMs are going to face stricter regulation as time goes on. All it takes is one reckless CPM who didn't transfer, and then the legislature will start talking about mandatory requirements for transfer. Etc.
From Caryn:
credential that exemplified the established standards for educational and psychological testing
As I understand it, they don't vett the content. Just the test design.
That's because DEMs are capable of self-regulating, and they know what content they want to test over, and no one knows that content better than they do. *cough*
From Jen:
"As I understand it, they don't vett the content. Just the test design.
That's because DEMs are capable of self-regulating, and they know what content they want to test over, and no one knows that content better than they do. *cough*"
Thank you. "Test design" was the phrase I was looking for, lol. It would have been much simpler than what I wrote, lol.
This is listed on the same page as that quote on NARM's website:
"Using the CPM as the basis for licensure shifts the responsibility and liability for all aspects of certification, including the ongoing psychometric evaluation of the written examination, to the North American Registry of Midwives."
That seems to say that the CPM's really have no oversight, except by NARM...and since they're teaching some pretty BS thoeries and topics, I'm not exactly feeling reassured @@
From Susanne:
State licensure also means that it can be mandated that one carry malpractice insurance for a certain amount, no? What insurance companies are willing to write policies for CPM's?
From Jolene:
"State licensure also means that it can be mandated that one carry malpractice insurance for a certain amount, no? What insurance companies are willing to write policies for CPM's?"
I have heard it said that no insurance companies do, and I've heard it said that they'll write policies for groups of CPMs that join together. So I really don't know.
However, it certainly can be mandated that CPMs carry insurance, just as it is mandated that CNMs do. And with the current administration, I wouldn't be surprised if it was mandated that insurance companies had to write policys for them as well.
From Susanne:
So, Jolene, you're on the train, but you haven't completed the train of thought. So now CPM's are licensed and require malpractice insurance. So now you're the head of a malpractice insurance company and you are contemplating writing a policy to cover CPM's. It has come to your attention that CPM's don't subscribe to - aren't even taught! - standard medical knowledge when it comes to a serious complication of pregnancy and instead have their own pet theory which doesn't stand up to scientific scrutiny. Does this make the likelihood that they will mismanage a woman (and hence be sued) more or less likely? Does this make you more or less willing to write them a policy? If you do, how does it impact the price you'll undoubtedly charge them for said policy? How does that price square with what they're able to afford given that they have a limited scope of practice and aren't otherwise "useful" in women's health care (the way that an OB does gyn care, prescribes birth control, does gyn surgery, etc.)?
From Susanne:
"And with the current administration, I wouldn't be surprised if it was mandated that insurance companies had to write policys for them as well."
Huh? What are you talking about? The government is not in the business of requiring med mal insurers to write policies to cover specific providers, any more than they are in the business of requiring Allstate to cover my car insurance if Allstate deems I'm not worthy based on my accident record.
I think you're confused about the difference between health insurance that an individual might carry (Blue Cross Blue Shield, Humana, etc.) and medical malpractice insurance that covers health care practitioners. These are two different markets and two very different things.
Jolene, medical malpractice insurance companies have already pulled out of many states and/or refused to cover certain practices. The Obama administration isn't "changing" that or telling these companies that they must underwrite doctors / practices that they can't make money on. Why would they? One can argue that access to health insurance is a universal right of all citizens (that's a whole 'nother topic) but no one argues that access to malpractice insurance is a universal right of all health care providers.
I really think you're mixing up the two.
From Alexis:
Susanne, one state (Washington) does operate a pool for DEMs. There are restrictions on what it will cover, and I'm told some LMs forgo coverage because of that (I don't know if doing an uncovered birth, eg HBAC, voids your insurance generally or only for that birth).
If the med-mal situation gets worse, though, I wouldn't be surprised to see the government (either state or federal) getting much more heavily involved, just as they are doing with health insurance.
There is an argument to be made that it's unfair to require people to purchase a policy which is not available. This is why there's an assigned-risk pool for car insurance. If states were to require that DEMs got insurance, they should also make sure that insurance is available. It does seem wrong to me (in the abstract) to enact a law which cannot be complied with even if the midwife wishes to. (This arose in the UK, where the government wanted to make independent midwives carry insurance. Right now no one will because the pool is too small to be viable. So the government has to decide whether to make insurance available in some other way, or drop the requirement.)
From Susanne:
"It does seem wrong to me (in the abstract) to enact a law which cannot be complied with even if the midwife wishes to. "
Ah - but there's the rub - the price. What if the only med mal ins policies for midwives come at costs that the average midwife cannot afford (let's say, for the sake of argument, $100,000 / year premium)? Doctors are paying this and more, but they have other skills that they can use because they do more than attend births (the aforementioned gyn care, bc pills, gyn surgery, etc.). If a doctor goes out of business because med mal insurance is more than he or she can cover, we say that's unfortunate, but we look to ways to reduce med mal premiums in the first place by tort reform. You'd think midwives would be all over tort reform because the same thing just trickles right back down to them. It's interesting how midwife associations and organizations have had little to nothing to say on tort reform. Which tells me again that it's about the dream of delivering fuzzy wuzzy baybees and not about the realities of being a licensed professional in America in 2009.
From Caryn:
If states were to require that DEMs got insurance, they should also make sure that insurance is available.
Three questions:
Would an insurance company willingly provide insurance for a subset of care providers who weren't obtaining informed consent?
Would the state require them to do so, and if so would the burden of failing to get consent somehow fall on the state?
If a provider carries a license saying that he or she is capable of recognizing and transferring care of preeclamptic patients, but the training of that provider means that he or she is actually incapable of providing the current standard of care for referral to OBs or MFMs, is that fraud?
From Yehudit:
Alexis, when you say " In a hospital, 1 midwife covers multiple patients until they're ready to push" it sounds like this is the routine practice upon which healthcare economics are based, rather than an exceptional situation that everyone acknowledges is wrong and that 1:1 is the goal.
I don't doubt that there is sometimes less than 1:1 care for women in active labour, especially in London hospitals. I do doubt that midwives are looking after three women in active labour at one time. (Which was the implication of your claim "until they are ready to push"). There is a distinction.
In the absence of a lot of workforce planning data, a good surrogate might be the healthcare commission report question on women in labour being left alone more than they were happy with (we might presume the most common reason would be understaffing).
15% of women surveyed (national average) answered yes to the question whether they were left alone more than they would have liked. Obviously, every individual woman who is left alone inappropriately in labour is one woman too many, but at 15% it doesn't seem like less than 1:1 care is the norm. Rather, 85% of women seem to be getting 1:1 in active labour (or at least, they are not feeling that they are left alone inappropriately in labour).
Obviously that varies around the country, and the many of the worst offenders are in London, but even in London there is a wide variety of responses: at Homerton 9% of women surveyed answered yes to this question, whereas at Barnet and Chase Farm 22% answered yes.
But no one think that less than 1:1 in active labour is acceptable standard of care, and reasonable cost comparisons can't be made on the basis of comparing substandard hospital care with standard care at home.
From Alexis:
But my point is not what SHOULD happen in hospital. It all comes down to the fact that in order to provide a larger home birth service, more midwives need to be hired. The government is not willing to pay for that. So I don't think we can say home birth is a cost savings if it requires additional personnel they're not willing to hire. My gripe here is really with politicians, not the NHS. Maternity services are a political football, and we all know that for the past decade the government has been obsessed with providing the illusion of choice, even when no such choice is available.
As for the patient satisfaction surveys, I was never under the illusion that I was going to get 1:1 care--all my antenatal classes told me I wouldn't. So those figures have to be stacked up against expectations.
From Alexis:
Susanne, the experience of states that have tried tort reform is that premiums have not gone down.
BTW, a CNM pays substantially less than an OB, so I would expect a DEM to pay what they do. An article last year in my area quoted a CNM (with a mixed home-hospital practice) as saying she paid $22K a year. A CNM is less of a risk for the insurers than an OB because she doesn't perform surgery and doesn't handle high risk cases.
From Jolene:
"Huh? What are you talking about? The government is not in the business of requiring med mal insurers to write policies to cover specific providers, any more than they are in the business of requiring Allstate to cover my car insurance if Allstate deems I'm not worthy based on my accident record."
Seriously Susanne. Noticed anything going on lately? The government is in "the business" of doing a lot of things it historically hasn't. requiring malpractice insurance to offer coverage is totally possible.
From Susanne:
"A CNM is less of a risk for the insurers than an OB because she doesn't perform surgery and doesn't handle high risk cases."
And a DEM is more of a risk for the insurers because she's practicing based off a faulty theory behind a common pregnancy complication, that she'll handle without having the ability to do so.
High-risk cases aren't what cause med mal premiums to be high. The vast majority of suits are / were over perfectly low-risk pregnancies that turned south for some reason. MFM's don't pay higher premiums than run of the mill OB's.
From Yehudit:
all my antenatal classes told me I wouldn't.
++++++++++++
NHS antenatal classes?
I don't see how it is possible to give less than 1:1 care in active labour, and conform to routine care (i.e. frequency of maternal/fetal obs, even putting to one side any 'support' role the midwife might have). Auditable policies for routine care in labour must exist in order for the hospital to qualify for CNST. You might get away with it by neglecting non-labouring women allocated to you, but I don't see that you could give the routine care to two labourers simultaneously.
The fact that NHS antenatal classes are telling women that they should not expect to get 1:1 care says a lot about that trust. If that is their official policy, they are lucky not to lose their CNST cover.
From Alexis:
Not NHS, NCT. (NHS antenatal classes in my area were a joke--if you worked or wanted your partner to come, you could forget it. I heard that West Herts [Watford] cut them altogether.) I'm simplifying somewhat, I don't want to get the teacher in trouble here--but I was definitely given the impression that I wouldn't have that kind of coverage.
And don't forget, I gave birth in Barnet right before the shit hit the fan there. This is a hospital that regularly closed to new admissions because, in their own words, "things could get dangerous". They still top the table for closures.
From Yehudit:
I don't dispute that more midwives are needed.
I do think that any maternity unit is in a very difficult position when it comes to closures to new admissions. If a unit almost never closes to new admissions, that may mean that women are being assessed in a visitors lounge, women being induced on antenatal ward are not transferred to delivery unit when they should be...
And yet, they get it in the neck if they close to new admissions, even if it is only for a matter of a couple of hours.
From Alexis:
Yes, I know sometimes it's necessary. But when it happens a hundred times a year, that's not bad luck: that's bad planning. It means the unit is routinely running at capacity with no room to spare. And yet the trust wants to close the consultant unit at Chase Farm.
From djsnjones:
I've been gone for several days, so I will respond to several items at once.
First of all, I decline to be bullied by Caryn on the subject of the Brewer Diet, as I was on another board. We simply come from a different paradigm of healthcare, and we will never agree on that issue, and probably several others, so I see no benefit in the kind of discourse that I experienced previously on that subject. Different kinds of women who conduct their lives within different belief systems will each choose the kind of health care that fits the paradigm that they prefer to live with. Beating up on health care givers who work within a paradigm that another group disagrees with does no one any good. Those who choose to study and understand the Brewer Pregnancy Diet accurately and follow it accurately and fully will benefit from it. Those who choose not to are welcome to find help elsewhere which fits their belief system and world view. I don't understand the need to bad-mouth and undermine others who disagree. In any case, I refuse to respond in kind.
CPMs do have an education that is equal of that of the CNMs--it's just different. It is geared to the different scope of care that CPMs are expected to give. It includes some information that CNMs do not get. In many places it includes a requirement of more supervised births than CNMs are required to have.
It is a matter of opinion on whether the CPM education is unscientific and based on bogus theories.
Neither CNMs nor CPMs are "trained". As I was taught in nursing school, dogs are trained. Nurses are educated. I would argue that the same is true of both CNMs and CPMs.
Neither RNs, nor CNMs, nor CPMs practice medicine. The practice of nursing and the practice of midwifery are distinctly different from the practice of medicine. You can ask any client of a nurse, a nurse-practitioner, or a midwife how differently they are treated than when they went to an MD or OB and you will get a piece of the answer. Any nurse or midwife could probably list for you a hundred ways in which they are different. Neither CNMs nor CPMs would ever want medical "training" or education. They seek CNM preparation or CPM preparation, instead of medical preparation, for the specific reason that they prefer the perspective provided by that specific type of education as being different from the medical paradigm.
And it seems to me that this debate is endless because we are just working from a different paradigm, which will not change. I suggest that those of you who are from a medical paradigm go to Dr. Marsden Wagner's website and read his "Fish Don't See Water" article. It explains why for those in the medical paradigm it will always appear to be safer to give birth in a hospital with an OB, and for those in the natural-birth paradigm it will always appear to be safer to give birth in a non-medical environment.
As far as insurance goes, it's been my impression that most homebirth midwives prefer to practice without malpractice insurance--CNMs and CPMs alike. And from what I've seen they usually do give informed consent. Before they even accept a mother as a client, they sit down with them and tell them what they are willing to do and what they are not willing to do. They usually make it very clear that the parents are taking on themselves the responsibility of their own health and birth, and that the midwife is there to help and advise them. They may even say that if at any point the parents decide to go against the midwife's advice, the midwife will have to decline to serve as their midwife any more. And then they may require the parents to sign that they understand these requirements and expectations. Most of the time, they wouldn't even have to go to these lengths, because most parents who choose home birth do so because they already believe that they are responsible for their own care and decisions.
To carry on one's practice in this way and then carry malpractice insurance would seem to be a contradiction. "I am an educated, competant practitioner, and you are on your own turf, making your own decisions about your care, but just in case I do something incompetant and take over your care and make you do something that you disagree with, I will carry malpractice insurance." I don't think so.
The other thing that carrying malpractice insurance does is that it puts a bull's eye on your back, encouraging lawsuits, even when it's unwarranted. It's my personal opinion, which I believe is also the opinion of at least some homebirth midwives (both CNM and CPM), that if you can tell clients up front that you do not carry that kind of insurance and have no money to give them, and that they are responsible for what they want to happen during their prenatal care and birth, you will end up with better outcomes and happier clients.
In fact, in my over-31 yrs of working in the natural-birth field, I have heard of only 2 families who sued their homebirth midwives, both of whom were CNMs. In one case, a lawyer talked the parents into suing for something that was probably not connected to the midwife's care (the father had what appeared to be the same condition), and in the other the parents may have refused to be transported to the hospital when the midwife advised them to (I'm not sure). It is said in the homebirth community that homebirth parents almost never sue, and that is probably because they already have a different way of looking at birth and homebirth than other people do.
As far as midwives having better outcomes because they only care for a low risk community goes, there was a significant study done in CA several years ago in which a county of pregnant women (both high and low risk) got care from only Family Practice physicians for a period of years, and then the same community (both high and low risk) got care from only CNMs for 3 years, and then the same community (both high and low risk) got care from OBs for two years. Under the Family Practice docs, the infant mortality rate was 23.9/1000, and the prematurity rate was 11.0%. Under the CNMs the infant mortality rate was 10.3/1,000, and the prematurity rate was 6.4%. Under the OBs, the infant mortality rate was 32.1 per 1,000, and the prematurity rate was 9.8%.
And as far as general homebirth or natural-birth education and practices standing up to scientific scrutiny goes....
"Only about 15% of medical interventions are supported by solid scientific evidence....This is partly because only 1% of the studies in medical journals are scientifically sound and partly because many treatments have not been assessed at all."
~ Richard Smith, editor of the British Medical Journal
"The international standing of the U.S. [in terms of infant mortality rates] did not really begin to fall until the mid-1950s. This correlates perfectly with the founding of the American College of Obstetricians and Gynecologist (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians who has sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked in 10th place or better. Since the mid-1950s the U.S. has consistently ranked below 12th place and hasn't been above 16th place since 1975. The relative standing of the U.S. continues to decline
even to the present."
(Stewart, David, International Infant Mortality Rates
--U.S. in 22nd Place,
NAPSAC News, Fall-Winter, 1993, p.3
Now in 2008, 15 years later, the U.S. is in 42nd place.
From Caryn:
I decline to be bullied by Caryn on the subject of the Brewer Diet, as I was on another board.
Joy, it is not bullying you to ask you to support your claims with evidence.
Have you got any yet?
From djsnjones:
I've been gone for several days, so I will respond to several items at once.
First of all, I decline to be bullied by Caryn on the subject of the Brewer Diet, as I was on another board. We simply come from a different paradigm of healthcare, and we will never agree on that issue, and probably several others, so I see no benefit in the kind of discourse that I experienced previously on that subject. Different kinds of women who conduct their lives within different belief systems will each choose the kind of health care that fits the paradigm that they prefer to live with. Beating up on health care givers who work within a paradigm that another group disagrees with does no one any good. Those who choose to study and understand the Brewer Pregnancy Diet accurately and follow it accurately and fully will benefit from it. Those who choose not to are welcome to find help elsewhere which fits their belief system and world view. I don't understand the need to bad-mouth and undermine others who disagree. In any case, I refuse to respond in kind.
CPMs do have an education that is equal of that of the CNMs--it's just different. It is geared to the different scope of care that CPMs are expected to give. It includes some information that CNMs do not get. In many places it includes a requirement of more supervised births than CNMs are required to have. CNMs also get some information that CPMs do not get. Both forms of education provide the kinds of information that each kind of practice needs. In some places that information is the same, and in some places it is different, just as in some places the need for some information is the same and in some places it is different.
It continues to be a matter of opinion on whether the CPM education is unscientific and based on bogus theories.
Neither CNMs nor CPMs are "trained". As I was taught in nursing school, dogs are trained. Nurses are educated. I would argue that the same is true of both CNMs and CPMs.
Neither RNs, nor CNMs, nor CPMs practice medicine. The practice of nursing and the practice of midwifery are distinctly different from the practice of medicine. You can ask any client of a nurse, a nurse-practitioner, or a midwife how differently they are treated than when they went to an MD or OB and you will get a piece of the answer. Any nurse or midwife could probably list for you a hundred ways in which they are different. Neither CNMs nor CPMs would ever want medical "training" or education. They seek CNM preparation or CPM preparation, instead of medical preparation, for the specific reason that they prefer the perspective provided by that specific type of education as being different from the medical paradigm.
And it seems to me that this debate is endless because we are just working from a different paradigm, which will not change. I suggest that those of you who are from a medical paradigm go to Dr. Marsden Wagner's website and read his "Fish Don't See Water" article. It explains why for those in the medical paradigm it will always appear to be safer to give birth in a hospital with an OB, and for those in the natural-birth paradigm it will always appear to be safer to give birth in a non-medical environment.
As far as insurance goes, it's been my impression that most homebirth midwives prefer to practice without malpractice insurance--CNMs and CPMs alike. And from what I've seen they usually do give informed consent. Before they even accept a mother as a client, they sit down with them and tell them what they are willing to do and what they are not willing to do. They usually make it very clear that the parents are taking on themselves the responsibility of their own health and birth, and that the midwife is there to help and advise them. They may even say that if at any point the parents decide to go against the midwife's advice, the midwife will have to decline to serve as their midwife any more. And then they may require the parents to sign that they understand these requirements and expectations. Most of the time, they wouldn't even have to go to these lengths, because most parents who choose home birth do so because they already believe that they are responsible for their own care and decisions and want their care-giver to agree with them on that.
To carry on one's practice in this way and then carry malpractice insurance would seem to be a contradiction -- "I am an educated, competant practitioner, and you are on your own turf, making your own decisions about your care, but just in case I do something incompetant and take over your care and make you do something that you disagree with, I will carry malpractice insurance." I don't think so.
The other thing that carrying malpractice insurance does is that it puts a bull's eye on your back, encouraging lawsuits, even when it's unwarranted. It's my personal opinion, which I believe is also the opinion of at least some homebirth midwives (both CNM and CPM), that if you can tell clients up front that you do not carry that kind of insurance and have no money to give them, and that they are responsible for what they want to happen during their prenatal care and birth, you will end up with better outcomes and happier clients.
In fact, in my over-31 yrs of working in the natural-birth field, I have heard of only 2 families who sued their homebirth midwives, both of whom were CNMs. In one case, a lawyer talked the parents into suing for something that was probably not connected to the midwife's care (the father had what appeared to be the same condition), and in the other the parents may have refused to be transported to the hospital when the midwife advised them to (I'm not sure). It is said in the homebirth community that homebirth parents almost never sue, and that is probably because they already have a different way of looking at and dealing with birth and homebirth than other people do.
As far as midwives having better outcomes because they only care for a low risk community goes, there was a significant study done in CA several years ago in which a county of pregnant women (both high and low risk) got care from only Family Practice physicians for a period of years, and then the same community (both high and low risk) got care from only CNMs for 3 years, and then the same community (both high and low risk) got care from OBs for two years. Under the Family Practice docs, the infant mortality rate was 23.9/1000, and the prematurity rate was 11.0%. Under the CNMs the infant mortality rate was 10.3/1,000, and the prematurity rate was 6.4%. Under the OBs, the infant mortality rate was 32.1 per 1,000, and the prematurity rate was 9.8%.
And as far as general homebirth or natural-birth education and practices standing up to scientific scrutiny goes....
"Only about 15% of medical interventions are supported by solid scientific evidence....This is partly because only 1% of the studies in medical journals are scientifically sound and partly because many treatments have not been assessed at all."
~ Richard Smith, editor of the British Medical Journal
"The international standing of the U.S. [in terms of infant mortality rates] did not really begin to fall until the mid-1950s. This correlates perfectly with the founding of the American College of Obstetricians and Gynecologist (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians who has sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked in 10th place or better. Since the mid-1950s the U.S. has consistently ranked below 12th place and hasn't been above 16th place since 1975. The relative standing of the U.S. continues to decline
even to the present."
(Stewart, David, International Infant Mortality Rates
--U.S. in 22nd Place,
NAPSAC News, Fall-Winter, 1993, p.3
Now in 2008, 15 years later, the U.S. is in 42nd place.
For those who like to see the studies and the numbers, I suggest "Five Standards for Safe Childbearing", available in your local libraries, or through inter-library loan, or through Amazon. I would also suggest that you read the links at the bottom of this page....
http://home.mindspring.com/~djsn...jones/
id78.html
Any studies that have ever been done on the subject of homebirth actually support the view that in childbirth less is more, and that the more we try to control or manage birth, the higher our mortality rates are--both for infants and for mothers.
Joy
From djsnjones:
And as far as using fetal monitors at home goes, the use of fetal monitors is one of the unnecessary hospital procedures that they are trying to get away from by choosing homebirth, and most homebirth parents would vehemently refuse to use them, even if they were available. In this list of articles, you will find 4-5 of them which discuss the hazards of the use of ultrasound....
http://home.mindspring.com/~djsn...njones/
id7.html
From Caryn:
It is a matter of opinion on whether the CPM education is unscientific and based on bogus theories.
Is it a matter of opinion whether or not the Earth is flat?
From Alexis:
Your claims make no sense, Joy. MDs make the same claims about their competence as midwives, and they carry malpractice insurance. If home birth midwives had money to collect you can bet they'd be sued--and if MDs didn't have money, they wouldn't.
Infant mortality is deaths up to ONE YEAR. It's basically irrelevant to birth. This is so basic it's unbelievable. Go look up perinatal mortality and see how the US does on that. The US does poorly on infant mortality because of high poverty rates and poor access to health care, not because ACOG is a greedy monopoly.
All your yammering about "paradigms" is meaningless. There is medical evidence and then there is not, and Brewer doesn't meet that test. Because you can't answer that, your response is to take your toys out of the sandbox and go home. And THAT is why no one takes Brewer seriously. Including most CNMs.
From Alexis:
And, finally, science is not just a "matter of opinion". Sometimes, there's not sufficient evidence to draw a conclusion. But ultimately, science is based on facts, evidence, and logic, not whether an idea sounds good. It's not liking strawberry or chocolate.
From djsnjones:
I think that anyone will look more professional and will be taken more seriously when they refuse to try to bully or harrass or ridicule someone into leaving or agreeing with them.
The issue of the safety of home birth continues to be a matter of opinion because the studies that have been done on the issue support the idea that home birth is safer, and yet those who prefer hospital birth don't want to believe those studies.
http://www.lamaze.org/Research/W...21/
Default.aspx
It seems to me that MDs carry malpractice insurance because they do so many things that are against the laws of nature that they have things go wrong that wouldn't have otherwise. So they need the malpractice insurance, where others who follow the laws of nature don't.
I can tell that you-all are not reading the sources that I'm giving you, because your responses don't account for the information contained in those articles.
Here is the official international infant mortality rates put out by our own government. So you're saying that these 41 other countries in the world have less poverty and access to health care than we do? Even Cuba and South Korea?
https://www.cia.gov/library/publi...r/
2091rank.html
"All your yammering about 'paradigms' is meaningless."
I disagree. Check out what this PhD says about the importance and influence of paradigm in childbirth...
http://www.davis-floyd.com/ShowP...Page.asp?
id=158
"There is medical evidence and then there is not, and Brewer doesn't meet that test."
See this page for over 130 years of evidence that the Brewer Diet does meet that test. Those who are opposed to the Brewer principles are simply choosing to disbelieve this evidence. So it remains a matter of opinion.
http://home.mindspring.com/~djsn...jones/
id80.html
"And THAT is why no one takes Brewer seriously. Including most CNMs."
I have a registry of hundreds of childbirth professionals from 13 countries and 49 states, many of them CNMs, and some of them doctors and PhDs, who do take Brewer seriously.
http://home.mindspring.com/~djsn...jones/
id97.html
"And, finally, science is not just a 'matter of opinion'. Sometimes, there's not sufficient evidence to draw a conclusion. But ultimately, science is based on facts, evidence, and logic, not whether an idea sounds good. It's not liking strawberry or chocolate."
Oh that it were that simple. Check this out....
http://www.lamaze.org/Research/W...21/
Default.aspx
From djsnjones:
"So you're saying that these 41 other countries in the world have less poverty and access to health care than we do? Even Cuba and South Korea?"
Sorry. I meant to say....
So you're saying that these 41 other countries in the world have less poverty and more access to health care than we do? Even Cuba and South Korea?
From Alexis:
I'm saying that you missed my point entirely. It is irrelevant whether the US is 1st or 191st in infant mortality, because that doesn't measure obstetric care. It measures outcomes for children. Birth is a very small part of outcomes for the entire first year of life. BTW, yes, Cuba does (or did, things are slipping) had better access to basic, primary health care than the US does for children. South Korea is a developed nation.
I can find MDs who believe homeopathy works. It doesn't mean most of them do, or that homeopathy works (it doesn't).
Joy, I've read your yammerings on that PE forum thread. You're being no more coherent or helpful here. All the doctors just want to ignore this fabulous miracle cure for PE. I don't buy it. PE kills and it's not as if "Big Pharma" is offering their own cure. If doctors could cure it via a diet, they would. Just like, you know, they put diabetics on special diets.
BTW, the studies do NOT say "home birth is safer". Even if the studies are right, they say it's AS SAFE--not safer. Lower chance of certain interventions, yes, but in terms of mortality--not safer. There's a difference.
From Caryn:
I think that anyone will look more professional and will be taken more seriously when they refuse to try to bully or harrass or ridicule someone into leaving or agreeing with them.
Joy, I'm not bullying you, harrassing you, or ridiculing you. Nor do I insist that you agree with me.
I'm asking you for evidence. The regular sort. The sort we get with observation, induction, and deduction, the sort that's peer-reviewed so other people can check to see if we've made any mistakes. The sort where the data is available for everyone to check. The transparent sort. Not the sort that boils down to anecdotes and assertions.
I have talked to multiple NICHD researchers about this; they'd all like to see Brewer advocates submit a rigorously designed study proposal. One where you're not confounding your data.
How does the Brewer Diet account for the HLA-C/KIR data? The HLA-C ligands for KIR on trophoblast cells may belong to two groups, C1 and C2 that are defined by a dimorphism at position 80 of the alpha1 domain. This maternal-fetal immunological interaction, occurring at the site of placentation, therefore involves two polymorphic gene systems, maternal KIRs and fetal HLA-C molecules. Uterine NK-cell function is thus likely to vary in each pregnancy. In pre-eclamptic pregnancies we have found that some KIR/HLA-C combinations appear unfavourable to trophoblast-cell invasion due to the overall signals that the NK cell receives.
How does the Brewer Diet explain shallow placentation?
How can the Brewer Diet eliminate the effects of trisomy? Women who are carrying a trisomy 13 fetus are more prone to develop preeclampsia. Excess circulating soluble fms-like tyrosine kinase-1 has been implicated recently in the pathogenesis of preeclampsia. Since the fms-like tyrosine kinase-1/soluble fms-like tyrosine kinase-1 gene is located on chromosome 13q12, we hypothesized that the extra copy of this gene in trisomy 13 may lead to excess circulating soluble fms-like tyrosine kinase-1, reduced free placental growth factor level, and increased soluble fms-like tyrosine kinase-1/placental growth factor ratio.
Why doesn't recommending that pregnant women restrict protein increase the rate of preeclampsia? In three trials involving 384 women, energy/protein restriction of pregnant women who were overweight or exhibited high weight gain significantly reduced weekly maternal weight gain and mean birth weight but had no effect on pregnancy-induced hypertension or pre-eclampsia.
IIRC, you've cared for around 1000 women. The rate of severe PE is 1%. That means it's entirely possible that you've never seen a severe preeclamptic in your population.
From djsnjones:
I did not miss your point. I simply disagreed with you.
There is a large section in "The Five Standards for Safe Childbearing" which discusses PMR, FMR, NMR, and IMR. Here is a small excerpt...
"The reason for recommending the tabulation of IMR, which requires following the child through the first year, is that IMR is the parameter used to compare maternity outcomes internationally. IMR also reflects not only the influences at and following birth, but also the long-term forms of care such as whether or not the baby is breastfed."
Whether or not homeopathy works is a matter of opinion.
"I don't buy it. PE kills and it's not as if "Big Pharma" is offering their own cure. If doctors could cure it via a diet, they would. Just like, you know, they put diabetics on special diets."
We simply disagree.
"BTW, the studies do NOT say "home birth is safer". Even if the studies are right, they say it's AS SAFE--not safer. Lower chance of certain interventions, yes, but in terms of mortality--not safer. There's a difference."
Again, we simply disagree. There are also many studies which also say that it is safer. Check out the matched-pair study by Dr. Lewis Mehl. He matched 1046 planned home births with 1046 planned hospital births. They were matched for maternal age, parity, socioeconomic status, education, and risk factors. Here are some of the results of his study...
--In the hospital, 3.7 times as many babies required resuscitation.
--Hospital: infection rates of newborns were 4 times higher.
--Hospital: 2.5 times as many cases of meconium aspiration.
--Hospital: 6 cases of neonatal lungwater syndrome (none at home).
--Hospital: 30 birth injuries (0 at home).
--Hospital: incidence of respiratory distress 17 times higher.
--Neonatal and perinatal death rates were statistically the same for both groups, but Apgar scores were significantly worse in the hospital.
--Hospital: 6 times more fetal distress.
--Hospital: 5 times more incidence of maternal high BP.
--Hospital: 3.5 times more meconium staining.
--Hospital: 8 times more shoulder dystocia.
--Hospital: 3 times more postpartum maternal g hemorrhages.
From djsnjones:
Caryn, for the answers to all of your questions, you can read my website.
From Jolene:
"Check out the matched-pair study by Dr. Lewis Mehl."
Is this the study done in 1976? Or is there a second one I'm not aware of?
From djsnjones:
This is the one done in 1977-1978.
From Alexis:
And yet, in the most recent WHO statistics, they say PMR is the correct way to measure obstetrical care. I wonder who to believe here? Further, your own quote belies your statement: they use IMR BECAUSE it factors in things other than obstetrics. In other words, it's not the best measure for what happens at birth. It is not useful for telling us whether our approach to obstetrics is better or worse than another.
And you quote a 30 year old study and expect me to take that as the last word?
From Alexis:
Frankly, you strike me as the worst sort of home birth advocate: the kind who spews facts and "data" without any clue about what it actually means. You're trying the dazzle-with-citations trick.
From Alexis:
Oh (and I apologize for serial posting but I'm seeing red here), once again, whether homeopathy works is not a matter of opinion. You appear to have a major misunderstanding of the difference between fact and opinion. If something can be tested and determined to be true, it is a question of fact. The efficacy of homeopathy is not a matter of opinion. it is a testable, measurable thing--and studies say no. (as do the laws of physics and indeed the entire history of homeopathy which is fundamentally made up). What you are doing is intellectually dishonest. The facts disagree with what you want to say, so you choose to reduce it to opinion, because people can't argue with opinions. If I like chocolate and you like strawberry, that's not something we can really settle. Science and medicine don't work that way. We can't say "that's your opinion" and leave it at that.
You come here, show absolutely no understanding of science, medicine, logic, or indeed rational thought, and expect me (and I'm far from the most anti-home birth person you'll meet) to take you seriously?
From djsnjones:
Alexis, I simply disagree with you. If you had read the article by Henci Goer about how research can be (and often is) misinterpreted and misrepresented by the mainstream medical sector of society, you would understand what I am talking about. If you had read the articles by Robbie Davis-Floyd on how one's belief system affects how they form their opinions, views, and research on childbirth, you would understand why I see these issues differently, and you would understand why I consider it a simple difference of opinion.
You can choose to insult me and put me down all you like, and try to invalidate my statements as much as you can, but you cannot change the facts.
From djsnjones:
You can choose whether to take me seriously or not. That does not change the truth.
You can also choose whether to accept the information from a 30 year old study or not. That also does not change the truth that was proved by that study.
That is part of the paradigm issue that I was talking about. You come from a paradigm in which studies older than a certain amount of years are no longer valid. Not everyone comes from that paradigm, including me--especially on certain kinds of issues, in which all the factors involved stay the same from year to year.
Am I to stop believing that the world is round or that gravity exists because the science that proved that is too old? I don't think so, and I don't agree with you on this one either.
From Alexis:
Nice strawman! I never said studies expired. However, newer studies have been done and obstetrics has changed. You're cherry picking an old study because you like the results.
I've read Henci Goer. What you're trying to do is set up a false dichotomy whereby there's this giant medical "paradigm". Instead of making it about individual, verifiable claims, you're choosing to present it as the outcome of a false worldview.
From Liz:
Henci Goer and Hart-Davies are hardly likely to impress or convince anyone here, as they use the same illogical sleight of hand you are displaying. Saying statistics CAN be misinterpreted is a truism. It doesn't demonstrate that their interpretion, or their dismissal of facts, is valid.
From Liz:
Don't know about you Alexis, but what gets up my nose is the smug certainty of people talking nonsense. Pointless to argue, really, but often irresistible.
From Alexis:
Oh, I know it's like talking to a brick wall because people like her will never be convinced--but there's smoke coming out of my nose.
Of course doctors can be wrong sometimes. Only a fool of an MD would tell you otherwise. But this kind of link and word salad is just the sort of impressive looking crap that people fall for.
And the fact that we don't fall for Floyd-Davies and Goer is, in her eyes, just evidence of our problematic worldview, so can all be explained away: we're dismissing her good "evidence" because we're predisposed to do so. Now, I'm prepared to grant that views of medicine are a valid topic of anthropology but it tells us nothing about scientific validity.
From Alexis:
Davis-Floyd, even, sorry. Liz, Hart-Davies is that bloke on the BBC who does stuff on what the ancients did for us. I knew that wasn't right but forgot to scroll back up to check.
From Liz:
I regularly get her name wrong, because I simply can't be bothered checking it. I know who she is though. I do get particularly steamed up when intelligent and educated people who really, really ought to know better assume that because they are highly qualified and intelligent, their reasoning is, must be, foolproof. If only! That the gullible swallow nonsense is not too surprising, but when academics fall in love with their own judgements, watch out.
From djsnjones:
http://www.lamaze.org/Research/W...72/
Default.aspx
From Alexis:
Study flawed! Next week, water wet. Honestly, Dr. Amy has pulled apart studies here before, from both angles. The fact that flawed research exists doesn't negate the scientific method.
Interestingly, even though you go on about the problems with medical research you're using studies as evidence. Does the medical paradigm work when it squares with your preconceived notions?
From Alexis:
(I can see how you can argue against RCTs--it's wrong, but logical. But to claim that other people are coming from a flawed medical paradigm when they demand such evidence, and then to use studies when it suits you--that's a problem of logic.)
From djsnjones:
Sigh. I cited them only because you asked for them.
I'm getting the distinct impression that you-all did not really want answers to your questions. I think that you only want to share your own perspectives on what's going on in the homebirth field with other people who agree with you.
So I will let you get back to that.
From Alexis:
No, actually, I'm perfectly prepared to hear cogent defenses of home birth. I'm actually one of the posters more critical of Dr. Amy on here. As a PE survivor I have little time for the Brewer diet, that's all.
If you don't care about scientific research, then the honest answer is to say "I don't believe scientific research has the answer". But your approach is the worst of both worlds and makes you look inconsistent.
From Kneelingwoman:
Just popped in from nowhere but Caryn, the NARM exam doesn't ask anything at all about the Brewer Diet and the Brewer Diet isn't an "answer" to give on the exam. How did you get to "see" what's on the NARM exam? It isn't typically given out to anyone except the people taking it?
What is true is that I don't think you can discount diet with preeclampsia and while there are no definative studies that affirm the diet hypothesis, none disconfirm it either! The fact is that I ( and other midwives ) have reversed very positive signs of Preeclampsia, by increasing protein to over 100 grams, adding large doses of calcium/magnesium, plus lots of water and moderate exercise and salting food to taste. The symptoms did reverse and did not return; I had perhaps a dozen or so women in my practice and only twice had to refer out for symptoms that did not improve, so I know it isn't foolproof but I have seen it "work".
From Alexis:
I think Caryn is going by the reading list. Also, Ina May is a vocal proponent of the diet, which annoys me because that's the sum total of the PE information in her guide to childbirth.
I do think we're overfocusing on the Brewer Diet though. It looks petty (and there's no need to tell me PE is serious, remember, so don't try that) and even if they did correct that, I don't think Caryn, Susanne, et al would suddenly go "oh, CPMs and their certification process are OK!"
KW, while I respect you, I know too many other cases of things that doctors/midwives/etc thought worked based on anecdote, which were disproven when they were studied. My inclination is to put Brewer in that category. People "see" all kinds of things work; without a controlled study, you don't know if the diet did it, the vitamins, or if it was a pure fluke.
BTW - while I'm sure only the candidates can sit the actual exam, there are no sample questions, similar practice tests, nothing available to non-candidates?
From Caryn:
Caryn, for the answers to all of your questions, you can read my website.
I'm not finding a discussion of trisomy or shallow placentation or the HLA-C/KIR data on there; could you link me to your data please?
Am I to stop believing that the world is round or that gravity exists because the science that proved that is too old?
Of course not; every time we go check more carefully, the evidence for gravity is still there. But the evidence for a nutritional component disappears when we look closely at preeclampsia.
Careful discussion about paradigms follows:
Joy, you have frequently asserted that various claims are "a matter of opinion." Sometimes, you argue for this by citing studies or evidence (usually of dubious value), but other times you assert that the truth of the claim depends on the paradigm that one accepts. However, these two sorts of argument are not compatible with each other.
When we say that something is a matter of opinion because there is contrary, conflicting, or scanty evidence, we are saying that it is reasonable to either accept or reject the claim, because whatever the fact of the matter is, no one has sufficient evidence to say for sure. It is a matter of opinion because we don't know. As I've repeatedly shown, your analysis of the available evidence is incorrect, and the totality of available evidence clearly fails to support Brewer's diet. But even if you were right, and the evidence were so inconclusive that we ought to say that the efficacy of Brewer's diet were "a matter of opinion" in this sense, then surely it would be irresponsible to risk your patients' lives on such an unproven methodology. Furthermore, the mere fact that something is currently "a matter of opinion" in this sense is no reason to cease debate and simply live and let live, as you seem to want to do. Precisely the opposite. If we really don't know whether the Brewer diet works, we should all continue to investigate it and continue to publicize, widely disseminate, and vigorously debate the results of all these investigations so that we can find out whether the claim is true or not.
On the other hand, when certain epistemologists claim that something is "a matter of opinion" because its truth is relative to a particular paradigm, they are asserting, not that the facts of the matter are not known, or even that they are not knowable, but rather that there is no paradigm-independent fact of the mater at all. This is supposed to follow from the fact that our background beliefs and values prevent us from observing the world in a completely objective way, thus preventing us from ever objectively testing our theoretical claims.
If you think that Brewer's claims are "matters of opinion" in this sense, then it really does make sense to cease our debate, since there is no fact of the matter that we are debating. However, it does seriously call into question why you would bother asserting those claims at all. Presumably, you are defending Brewer's diet because you think that it is a fact that it will improve the health of women and their babies. If this is not a fact, then why not just say that you would prefer that women follow this diet, in the same sense in which you prefer chocolate to vanilla ice cream (or whatever)? After all, it's only a matter of opinion, so what's it to you if most women decide not to act in accordance with it? For that matter, what's it to you if the rest of us bullies use the nasty old medical model to sway women around to our side?
Perhaps your response here is that you think we can make our own reality by adopting a paradigm with attractive health consequences. But even this won't help. If the medical facts are really paradigm dependent, then, sure enough, those who accepted your paradigm would find that Brewer's diet works for (most of) them, since accepting that is part of accepting the paradigm. However, the same would be true of women who accept the medical model. Since that model says that (most) women who receive proper biomedical care will have better outcomes than those that don't, then it would be a fact, relative to that paradigm, that such women will do better. If it is a fact, relative to their respective paradigms, that both sets of women will be fine, what does it matter which paradigm they accept?
In any event, however, the fact that our knowledge of medical (or other) facts is affected by the paradigms we accept does not even remotely entail that there are no objective medical facts. First of all, even if it were true that all of our purported knowledge of medical facts were thoroughly unreliable because of the subjectivity induced by our paradigms, objective facts would still stubbornly remain. This is the point that various people have been making when they point out that whether or not you get sick doesn't depend on the paradigms you accept. You can't just make up reality, because reality already beat you to it. Furthermore, it is false that paradigm-induced subjectivity is an impenetrable barrier to objective knowledge, since there are methods for containing the subjectivity of paradigms, which include things like peer review and an insistence on the repeatability and statistical significance of empirical studies. Collectively, these methods are called empirical science, which is part of the medical model you so despise. I suspect that one reason you think this is all a matter of opinion is that you've rejected the one "paradigm" that has any hope of making it otherwise.
From Caryn:
I do think we're overfocusing on the Brewer Diet though. It looks petty (and there's no need to tell me PE is serious, remember, so don't try that) and even if they did correct that, I don't think Caryn, Susanne, et al would suddenly go "oh, CPMs and their certification process are OK!"
The Brewer Diet, because of the postmodernist holistic claims embedded within, is the *perfect* testing ground. But it's only an example.
From Caryn:
Just popped in from nowhere but Caryn, the NARM exam doesn't ask anything at all about the Brewer Diet and the Brewer Diet isn't an "answer" to give on the exam.
The texts on the recommended reading list all assert Brewer wrt preeclampsia and none assert the mechanism as currently understood. I've checked.
From Caryn:
http://www.indyweek.com/gyrobase...id=oid%
3A258691
Economics aside, Dorn said, if more women with normal pregnancies had their prenatal care attended by midwives, rates of pre-eclampsia (high blood pressure in pregnant women), low-birth-weight babies, and complications during labor would fall. He says that's because obstetricians have very little training in nutrition and social issues that are crucial to healthy pregnancies.
So the advocates of CPM legalization are obliquely citing the Brewer Diet as empirical support for their claims, despite the absence of actual empirical support for it.
From Skeptical Midwife:
Wow. I have to say that this one of the most bizarre discussions on the practice, politics, and regulation of midwifery that I have ever seen. And that is saying a lot. Impressive.
Amy has left this discussion for the bigger waters of Salon, and because the tides have turned policy wise and research wise in a pretty definitive way this past year in this debate, if you can call it that here. And really there is only so many ways that you can mutilate science before it catches up with you and people stop listening, especially where there is no dialogue, only bashing.
There have been a number of articles in the scientific literature about torturing statistics -
http://www.medscape.com/viewarti...warticle/
588146
Stats for the Health Professional
Waterboarding and Wilcoxon: What Medical Researchers Might Learn About Statistics From the CIA
Andrew J. Vickers, PhDMedscape Business of Medicine. 2009; ©2009 Medscape
Posted 02/18/2009
The impossibility of doing a RCT with birth location-
Why women do not accept randomisation for place of birth: feasibility of a RCT in the Netherlands
Study conducted at the Maastricht UMC+, PO Box 5800, 6202 AZ Maastricht, the Netherlands
Copyright Journal compilation © RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
KEYWORDS
Home birth • hospital birth • randomised controlled trial • the Netherlands
I feel like I am possibly jumping into a discussion of how many angles can fit on the top of a pin if I choose to address some really, really basic false premises and understandings about the nature of EFM, Brewer diet, Malpractice insurance, and some other wildly inaccurate assumptions about CPM credentialing and the practice of attending births, home or hospital.
I only choose to address these things to at least engender a debate based on facts. Some of you may be able to work with these facts, others it appears are so locked into a particular belief that what I post will make no difference.
1)EFM is performed with hand held dopplers at home as it is at birth centers. Midwives are trained to do beat to beat variability with this device and record it.
2) Everything is electronic theses days. Docs have programs on their computers that link into the hospital network and they can remotely view tracings from home or office. There is even an iphone app for doing this that many docs have. The physician that provides collaborative care for many of my patients is able to remotely view tracings at home and observe labor flow charts as the nurses enter it.
3)Malpractice insurance is NOT REQUIRED for ANY health care providers in most states and some physicians practice bare. Malpractice insurance is required by hospitals for admitting privileges.
4)The CMP is based on the Brewer Diet??? What???? Why don't one of you fine people go download the set of 200 skills from the NARM website that must be signed off as PART of a CPM's basic training and count how many skills out of those 200 even mention the Brewer diet. What hogwash! Maybe I missed that part or the part on crystals and chicken bone waving. Or maybe that is a continuing ed. segment that I have yet to take. Please correct me if I am wrong.
5)"Midwives desire no accountability and want to be free as birds" Interesting, nice spin. And totally out the window as midwives have the gold standard for informed choice policy. I offer as evidence Virginia, where the midwives joined with the physicians recently to require a full disclosure requiring "evidenced based care" to all maternity patients. And you can bet that midwives will be driving this policy of transparency in maternity care state by state. A historical oppression and exclusion from policy making does not a "free as a bird" mentality make. As CPMs become integrated into the larger health care landscape and can contribute meaningfully to policy around health care disparity, transparency, and evidenced based care, this notion will loose what ever footing it is assumed erroneously to have.
Home builders do not regulate teachers. Nail technicians do no regulate plumbers. All professions offer regulatory oversight over their own professions by and large. State regulatory agencies get this. It is basic administration policy.
So please, continue along, just please, if Amy is not here, at least check your facts before you begin to mangle them.
From Yehudit:
I ( and other midwives ) have reversed very positive signs of Preeclampsia
++++++++++++
What is a very positive sign of preeclampsia in your book? Would that be the results of a 24-hour urine collection and/or blood tests including LFTs? Or simply raised BP and a dipstick? Because if it is the latter, I'm not surprised that many spontaneously resolve with or without dietary changes.
From Yehudit:
I applaud UK midwives.
++++++++
That's kind of you Caryn. There are only 14 Brewer-friendly 'birth professionals' listed in the UK - most of them doulas/hypnobirth people (I think there is one nutritionist, which is basically our name for a quack pretending to be a dietician). There are NO midwives, not even a frequently-derided-here non-NHS midwife.
Doesn't this show that Brewer diet has nothing to do with homebirth debate? (Since homebirth is a small but integral part of the UK maternity services, and every midwife is qualified to attend homebirths by virtue of their registration).
From Susanne:
Skeptical midwife, in my state, OBs most certainly are required to carry malpractice insurance to have privileges at a hospital. I believe the policy minimum is $2 mil but I might be mistaken on the dollar amount. You cannot go bare here.
From Caryn:
Maybe I missed that part or the part on crystals and chicken bone waving. Or maybe that is a continuing ed. segment that I have yet to take. Please correct me if I am wrong.
Skeptical Midwife, you may have been protected by your skepticism.
Here's the NARM primary reference list.
Here's what the first book on the list says about preeclampsia: There is ample empirical evidence that preeclampsia directly results from protein deficiency and malnutrition...
Interestingly, they cite none of this ample empirical evidence.
Here's what the third edition of _Spiritual Midwifery_ says: in the third edition, says that "the results we have had with the 1723 pregnancies under our care tend to support Dr. Tom Brewer's contention that toxemia is a disease of malnutrition, especially when the mother's diet is very low in protein...
(It keeps going. I've checked Varneys, which suggests bedrest to left side and increased dietary protein. I've checked Anne Frye, which goes into a long discussion about albumin and how it leaks from blood vessels when you're short dietary protein. The other books either mention Brewer, or don't mention a modern understanding of the syndrome.)
The "other useful books section" contains the Brewer books, Bradley, and so forth. (I would provide more links, but Haloscan will fuss.)
That's a *lot* of references in primary and secondary source material (and there are more) to a falsified theory. There's no mention of the syndrome *as currently understood*.
Home builders do not regulate teachers. Nail technicians do no regulate plumbers. All professions offer regulatory oversight over their own professions by and large.
It's the "by and large" that's in play here, and it's because as I pointed out above, the state cares more about professions where the clients live or die based on the practice of the profession than it does about the ones that don't.
Who is it that you would *ask* about the current understanding of the mechanism of a disease? Peer-reviewed published scientific researchers, many of whom in the case of pregnancy diseases are MFMs. This doesn't mean you're putting one profession under the oversight of another. This means you're asking scientists about the way reality is, and then modifying your expectations of the profession in question to reflect that reality.
Why shouldn't the medical care portion of what it is that midwives do be under the jurisdiction of the experts in medical care?
The state recognizes one epistemology. Because it's the one *everyone* recognizes when they go to find their car keys, the one that uses observation, induction, and deduction.
Can you answer the question I asked earlier? At which point in a birth is a midwife still doing her job, but an OB wouldn't be doing hers? Where's the line?
From Caryn:
Doesn't this show that Brewer diet has nothing to do with homebirth debate? (Since homebirth is a small but integral part of the UK maternity services, and every midwife is qualified to attend homebirths by virtue of their registration).
At best it shows that practice differs, I'd think. But that's the whole question: in what way does practice differ, and where's the line between midwifery, and *not* midwifery?
From Liz:
I had a very frustrating conversation with my sister (intelligent, well informed) today along the lines of "but everyone's blood pressure goes up". My fears for my daughter are not based on the idea that she will get pre-e again, but that she might get it and be in the care of someone who thinks it is no big deal. Kneelingwoman, you have successfully reversed the early signs with diet. Congratulations. Have you ever come across a case that has progressed so rapidly that the life of the mother or the baby was on the line? Fortunately, it is rare. But no-one who has any personal experience of it is going to be happy with the idea that diet is much of a factor.
From Yehudit:
It shows the there is no *inherent* link between
a) offering and attending home births
b) theories about pre-eclampsia and diet.
You seem to think that criticism of Brewer diet believers is somehow a criticism of home birth, when in fact it is a criticism of Brewer diet believers. The fact that there is an overlap in the US is pure historical accident.
From Caryn:
Some interesting reading:
http://skepticblog.org/2008/12/1...ative-medicine/
From Caryn:
You seem to think that criticism of Brewer diet believers is somehow a criticism of home birth, when in fact it is a criticism of Brewer diet believers. The fact that there is an overlap in the US is pure historical accident.
I am arguing that talking about homebirth necessarily comes down to talking about providers, and what it is that we expect them to do as a necessary part of their profession.
From Yehudit:
You can elide the issue of providers (and their qualifications) with place of birth if you want to. And that may make a certain kind of sense if you are within a system in which all home birth providers are also Brewer believers.
However, it is obvious that home births can be attended by a number of different providers (or none, if we include unassisted births) - and historically have been (e.g. there was a time when family doctors attended homebirths in the UK). Similarly, hospital births can be attended by a variety of providers (for example in the UK, pretty much all spontaneous vaginal deliveries are managed by midwives, whereas in the US the vast majority of SVDs are managed by obstetricians). The antenatal care for a woman planning a home birth can be identical to that of a woman planning a hospital birth (and is in the UK, with the possible exception of a scan for presentation).
At the very least, it becomes important to specify the provider/antenatal care received, when commenting on the safety of home birth.
From Ericacrochets:
"At the very least, it becomes important to specify the provider/antenatal care received, when commenting on the safety of home birth."
I would agree, and KW's showing up and talking about how she "reversed preeclampsia" and your obvious knowledge of the subject is a perfect example of this. I'm glad she spoke up and showed us her true colors, so to speak.
From Alexis:
I don't think the Brewer Diet says anything about home birth, per se, but it does say something about the body of providers who are performing it (and advocating for it) in the US. There doesn't have to be a link, but in this case, there is.
As for spontaneous resolution, I spilled protein at 22 weeks. At my next visit I didn't. No diet involved.
From Jolene:
S Midwife, thanks for taking the time to post. Sadly, most posters with direct knowledge of direct entry midwifery threw up their hands and walked away a long time ago.
"2) Everything is electronic theses days. Docs have programs on their computers that link into the hospital network and they can remotely view tracings from home or office. There is even an iphone app for doing this that many docs have. The physician that provides collaborative care for many of my patients is able to remotely view tracings at home and observe labor flow charts as the nurses enter it."
I assume by this quote you are a hospital based midwife. Do you have any ideas why my friends (home birth midwives) are as yet unable to send digital traces from home? Is it simply that they need to purchase the correct USB port/computer combo, or is it simply not high on the list of prioritys?
From Yehudit:
As for spontaneous resolution, I spilled protein at 22 weeks. At my next visit I didn't. No diet involved.
++++++++++++++
Are you saying that you had developed pre-eclampsia at 22 weeks, and it went away by your next visit? Or simply that the dipstick showed protein at 22 weeks and not at your next antenatal check?
Protein shows up for any manner of reasons. Dipstick sample tends not to be a 'clean catch' and contamination from increased vaginal discharge in pregnancy can cause protein to show up in the sample. I suspect that discussion with women about how to collect a clean sample would get rid of most of our false positives for proteinuria. (And avoid a lot of repeat samples, MSUs and further investigations).
The earlier finding on the dipstick may or may not have had anything to do with the later pre-eclampsia (but my understanding is since this is a progressive disease, if you have proteinuria as a result of glomerular endotheliosis then it is not going to go away - so for this reason I wouldn't necessarily associate your early dipstick with protein with your later development of pre-eclampsia).
From Caryn:
At the very least, it becomes important to specify the provider/antenatal care received, when commenting on the safety of home birth.
Exactly.
I'm not actually against homebirths. Or midwives. I have plenty of friends who still have homebirths; I work regularly with midwives.
BUT: those midwives are not using pseudoscience in their practice, and I would say at the very least that the difference between midwifery and *not* midwifery has to come down to the use of the scientific facts about the world when providers are making recommendations and when providers are explaining the the sorts of things relevant to informed consent.
From Jolene:
Caryn,
"I've checked Anne Frye, which goes into a long discussion about albumin and how it leaks from blood vessels when you're short dietary protein."
I am way over my head with the pre-eclampsia thing. Can you explain (or link to) why the albumin/protein theory is wrong?
Liz, I sympathize with your frustration with your sister. During my first pregnancy, my B/P went up to "near the limits" of pre-eclampsia cut-off, though I never had protein in my urine. My midwife (not homebirth) did encourage me to focus on protein and salt, and told me basically the same thing your sister said. Everybody's B/P goes up during pregnancy.
Interestingly, when the baby was born (spontaneously, at term), the placenta was very small.... smaller than a salad plate. And baby was 5 lbs.
I've never been able to figure out what that means. Did I have placental issues? (it seems I did) but it wasn't pre-eclampsia? My rising
blood pressure was clearly necessary for baby to survive.
Was this pregnancy path or normal? Was the advice/management good or bad?
When we talk about pre-eclampsia are we really talking about one extreme on a continuum that encompases a lot of normal women who are treated like they have pre-e and really don't? (KW) In other words, is there an element that exists here, of women in hospital being led to believe they were snatched from the jaws of death, when all likelihood is they would have spont reversed on their own?
Perhaps that's the reason women in the care of homebirth midwives seem to be "cured" by diet? I bet there is a lot of overlap between the two groups.
From Caryn:
Dipstick is also highly responsive to hydration, which is what's so disturbing about midwives who recommend more fluids when they see a trace or a +1 on the dipstick.
From Caryn:
Jolene, see the link above where I replied to Joy, saying that I had been over this with her before in great detail. Or start here, particularly the New Yorker article and the NYTimes article.
From Yehudit:
I'm not actually against homebirths. Or midwives.
+++++++++++
This is not the impression given, and I think that is due to the habit of generalizing on this blog (e.g. I make a perfectly reasonable statement about differences in clinical judgment - and your response seeks to conflate midwifery practice with belief in the Brewer diet).
From Caryn:
This is not the impression given, and I think that is due to the habit of generalizing on this blog (e.g. I make a perfectly reasonable statement about differences in clinical judgment - and your response seeks to conflate midwifery practice with belief in the Brewer diet).
In my experience, people don't actually read what it is that I'm saying before they react to it.
From Yehudit:
Pre-eclampsia does not spontaneously reverse before the delivery of the placenta. This is practically a definition of the disease! Of course, someone can get an incorrect diagnosis, but that is not what is being suggested.
No pre-eclamptics are being 'cured' by diets. Some women who have raised BP and/or proteinuria at one antenatal check are then having that resolve. That can happen for any number of reasons, depending on the reason for the raised BP or proteinuria.
From Yehudit:
In my experience, people don't actually read what it is that I'm saying before they react to it.
+++++++++++++
Well, I will have to pay attention. But if I post:
"I don't think the actions of any doctor or midwife in the UK is driven by the idea that 'dead babies are cheap.' ...Yes, sometimes people make different clinical judgments. These are based on clinical arguments about when is best to intervene from point of view of mother and baby, the balance of risks and benefits, and the interests of the many vs. the few."
And you respond "Or apparently, sometimes, they're based on false theories instead of clinical arguments."
Then you would appear to be taking a potshot at UK midwives (and doctors too, perhaps?) for basing their clinical judgments on 'false theories'. (And since the topic of discussion was Brewer Diet, I took this to be the specific false theory alluded to - but perhaps you meant nursing theories? We are mercifully free of those, not being nurses an' all.)
From Jolene:
"Pre-eclampsia does not spontaneously reverse before the delivery of the placenta. This is practically a definition of the disease!"
Thank you for that reality check.
From Caryn:
Yes, but again, the topic of discussion is not Brewer; that's simply an example. Who counts as a midwife? My point was that while UK midwives may be making clinical judgements, US midwives may be making non-clinical judgements. Backing homebirth in the US on the grounds that it works fine in the UK (as Holly did) doesn't take into account the differences in the professional training.
Our CPMs want to ally themselves with UK midwives. Do UK midwives want their authority and record to be co-opted by people using pseudoscience and who at least sometimes are failing to obtain informed consent because they're incorrectly advising their clients with respect to the way reality works? Do CNMs want to ally with them despite the fact that their reference books and schools teach pseudoscience? (To hear Holly tell it, yes.)
Nurses and midwives have agreed that what they're doing isn't medical care, except it's based on the same principles, except when it's not, and no one should be able to insist that they use science because they're perfectly capable of self-governing. Two nurses *in this thread* have endorsed the Brewer Diet, one more enthusiastically than the other. At least Jolene and I have been recommended to it or understandings of reality based on it. Why is that not nursing *or* midwifery, and wouldn't you agree that when we talk about homebirth, we have to agree about what it is we're talking about here?
From Alexis:
Yehudit, exactly what I said: I spilled protein at 22 weeks (positive dipstick), along with BP of 140/95. (It sent me straight into the arms of the consultant and a day in DAU.) I did NOT say I had preeclampsia at that point, because I didn't. I did develop it later on. However, it would appear to be a case where someone showed "positive signs" of PE, which resolved spontaneously. My eventual preeclampsia was resolved by emergency Caesarean.
If my midwife had told me to change my diet, she might have viewed the improvement as due to her intervention, when really, it was chance. I have no idea why I spilled protein at 22 weeks and honestly I suspect it was contamination or some other fluke. But it's very easy (and a common fallacy) to ascribe the outcome to some intervention made, rather than that kind of fluke.
From Liz:
"Pre-eclampsia does not spontaneously reverse before the delivery of the placenta."
And not always then. (Which was news to me - my daughter, normal BP 110/65, had sky high blood pressure for several days after delivery) What drives me mad is the idea that pre-e presents with a nice tidy set of clear cut symptoms. My conversation with my sister was along the lines of: Well, I had high BP, protein and odema, and I was fine. She was delivered at 40+ weeks, and maybe the disease did not occur early enough to do much damage. Or, maybe, her current ill-health is part of it. Personally, I do not want to pay too much attention to current research about the effects it can have in later life. My beef is that there are so many theories, so many blind alleys, that things like the Brewer Diet can seem plausible. Maternal fetal conflict seems a lot more plausible to me - but what am I to do with the idea that, unlike Caryn, Susanne and Emma B, my baby got the worst of that conflict? My blood pressure didn't go very high, not till the end - my baby had a stroke. In my day, placental function tests were done - the results were inconclusive, with false negatives and false positives, and it looks as if maybe in the future rather better tests might be available, but I don't think it is just midwives who have their pet theories. What do you do with early onset? Are the present tests good enough? Is it better in than out, and where is the line? Is proteinurea without elevated BP a problem? When does PIH become pre-e? I am no expert - just someone who finds pre-e very scary indeed and complacency about it terrifying.
From Yehudit:
Yehudit, exactly what I said: I spilled protein at 22 weeks (positive dipstick)
+++++++++
I was reading "spilled protein" to mean leakage (i.e. spilling) of plasma protein into the urine caused by damage to endothelial tissue - sorry for the confusion.
From Alexis:
Sorry, yes, if you're being specific about it, then I was incorrect - I've seen "spill" used much more loosely.
From Susanne:
"Maternal fetal conflict seems a lot more plausible to me - but what am I to do with the idea that, unlike Caryn, Susanne and Emma B, my baby got the worst of that conflict? My blood pressure didn't go very high, not till the end - my baby had a stroke."
Liz, not that it would make you feel "better," but one of my twins (ds) was affected by the preeclampsia conflict, insofar as he was severely growth restricted in utero. Dd was but to a lesser extent.
Ironically, dh's partner's wife had a pregnancy in which the child had a stroke in utero - he has some paralysis of one side (leg and arm) as a result; I am not sure of the extent to which he has cognitive difficulties. Just goes to show that both the wives in the practice had complications, because shit happens.
Anyway, the lead researchers in the field believe there is merit to maternal/fetal conflict, so that's good enough for me. No DEM's or CPM's midwives are "lead researchers in the field," because they don't even have the skills to do so nor the education to figure out plausible biological pathways.
From Susanne:
"That is part of the paradigm issue that I was talking about. You come from a paradigm in which studies older than a certain amount of years are no longer valid. Not everyone comes from that paradigm, including me--especially on certain kinds of issues, in which all the factors involved stay the same from year to year."
You don't get it. The paradigm isn't that studies older than X years are no longer valid. The paradigm is that studies that can't be replicated aren't valid. Brewer has never been replicated. People who are scientists above the I-read-it-on-the-Internet level desire replication status to call something valid.
From Yehudit:
Nurses and midwives have agreed that what they're doing isn't medical care, except it's based on the same principles, except when it's not, and no one should be able to insist that they use science because they're perfectly capable of self-governing.
++++++++++++
We have been round this before though, and you weren't satisfied then with my answers and I still have no better ones to give. I think the definitions of midwives' sphere of practice and skills outlined by the NMC, ICM/FIGO/WHO and EU are pretty good comprehensive definitions, and also fairly consistent with each other. These are likely similar to the ACNM definitions, I don't know.
From Caryn:
What do you do with early onset?
Deliver, unless a) you can stabilize the mother and push it a few more days and b) that will buy you necessary gestational time, because the baby's fine, just too early. There is lots of debate in the field about whether or not to even try temporizing management because of the risk to the mother. Any woman will volunteer to take the hit for her baby, but that's considered an inherently coerced form of consent.
Are the present tests good enough?
No, but we've not yet developed a test better than the ones we've got. They're in the process of developing both soluble factors testing and a new urinalysis screen (for things like urinary podocytes), but they've needed to add multiple additional tests like uterine artery Doppler, to improve sensitivity and specificity. At the moment, IIRC, the best one picks up two of every five pregnant women and still misses some preeclamptics. That's because all pregnant women are walking so close to the line.
Is it better in than out, and where is the line?
Right now? Again IIRC, and I'm no doc just an interested party, it's BPP less than 4/8 and more than 26 weeks gestation, or absent diastolic flow and a baby who isn't growing and a mother with one or more markers for severe preeclampsia, or reverse diastolic flow, or one or more markers for severe preeclampsia at 34 weeks gestation, or any of a host of other factors. There is some of this in the NIH Working Group Report, some in PRECOG, and constant ongoing research.
Is proteinurea without elevated BP a problem?
Maybe. Many women with underlying kidney disorders spill protein first and see their pressures elevate later.
When does PIH become pre-e?
One of the top researchers in the field calls it non-proteinuric preeclampsia. Some of those women are just unmasked chronic hypertensives, and some of them are women who are closet preeclamptics (elevated angiogenic factors, but they deliver before tipping over the PE diagnostic threshold,) and so forth.
They really are working on it -- it's a very hot research field -- but it's hard.
From Caryn:
We have been round this before though, and you weren't satisfied then with my answers and I still have no better ones to give.
But I assume you see the problem, which is all I'm driving at. I'm not asking you for an answer, or for the current answers (which are inadequate), but rather pointing out the problem.
From Liz:
Caryn, the NCB mantra is that doctors are just dying to find an excuse to intervene, and will do so at the least sign. I will acknowledge that I am super-sensitive, but that is not the impression I get here in the UK. Maybe the fear of litigation is not so powerful here, which of course is a good thing on the whole. Its hard to tell, as anecdote is unreliable, but the number of stories of doctors/midwives who do not pay attention to warning signs is still scary to me.
From Caryn:
Caryn, the NCB mantra is that doctors are just dying to find an excuse to intervene, and will do so at the least sign. I will acknowledge that I am super-sensitive, but that is not the impression I get here in the UK.
It's not the impression I get here, either. And I *do* have the impression that many NCB advocates don't understand enough science to understand why these interventions are the best management we have, so they think they're overkill. But I routinely hear from preeclamptics who are wondering why their doctors aren't moving to deliver right now, and the answer is, well, because technically there are no indications for delivery!
Its hard to tell, as anecdote is unreliable, but the number of stories of doctors/midwives who do not pay attention to warning signs is still scary to me.
This is precisely why the Preeclampsia Foundation exists. And APEC. And their CME courses. And PRECOG. We're working on it, I promise.
Did your daughter get an MFM appointment yet?
From Yehudit:
But it's only the same problem with defining what constitutes any profession. What is a "teacher" - well, we might say anyone who teaches, and then what does it mean to teach? There will be a lot of different definitions, quite a lot of overlap. Then there are statutory definitions, and qualifications. I'm less interested in an essential definition of "what is a teacher" applicable in all times and places, then in the use of workable definitions within a specific context.
There were doctors prior to germ theory, but a doctor TODAY who doesn't believe in germ theory isn't worthy of the label doctor. That doesn't mean that it makes sense to say that James Young Simpson (Professor of Midwifery at Univ. of Edinburgh from 1839) was not a doctor.
I don't have a problem with the current definitions of the midwife drawn up by the ICM/FIGO/WHO, and similar used by the EU and NMC. I see no difficulty with a similar definition being used in the US. I think these answers are adequate to the practical task, even if they can't address the "essential definition" (any more than you could provide an "essential definition" of teacher, that was also adequate to the practical task).
From Caryn:
But it's only the same problem with defining what constitutes any profession.
No, it's actually a huge, broadly recognized problem for the profession, and the focus of a whole lot of academic work.
From Yehudit:
Caryn, why are you ignoring the definitions of midwifery that I've cited?
I thought you were talking about a categorial/logical problem? (This is what I thought your midwifery/non-midwifery issue was)?
From Caryn:
Because, as you've pointed out above, when our understanding of the world changes, statutory definitions have to be rewritten.
This is precisely what the NC legislative review committee is in the process of doing -- *defining* what it is that counts as a midwife in NC.
Can they do it wrong?
From Yehudit:
Depends what you mean by "wrong".
If by "wrong" you mean, "can their definition be refuted on grounds that it doesn't match some "essential" definition of the midwife"? Well, yes, if they defined a midwife as someone who can competently wire your house for electricity - that would be pretty much wrong on those grounds.
If by wrong you mean, "can their definition be inadequate to the task of protecting women and their babies"? Well yes, of course. If it doesn't demand a level of education or training that will protect women and their babies, or define the sphere of practice in a way that will protect women and their babies.
As I've said above, I think the ICM/FIGO/WHO definitions are reasonable - since they allow the exact educational programme for midwives to be specified locally (what is appropriate in one context may not be appropriate in another). They also specify however that those locally recognized qualifications produce a person who is "able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help."
From Caryn:
If by "wrong" you mean, "can their definition be refuted on grounds that it doesn't match some "essential" definition of the midwife"? Well, yes, if they defined a midwife as someone who can competently wire your house for electricity - that would be pretty much wrong on those grounds.
So you'd agree there is some essential definition. I'll grant that it's a vague concept, but it has clear instances and non-instances. In particular I think we should be able to rule out using pseudoscience as a way of managing medical conditions.
If by wrong you mean, "can their definition be inadequate to the task of protecting women and their babies"? Well yes, of course. If it doesn't demand a level of education or training that will protect women and their babies, or define the sphere of practice in a way that will protect women and their babies.
So you'd say it's the job of a midwife to practice in a way that protects women and babies. So does the definition you've quoted, and it also suggests that the midwife has the job of conducting deliveries on her own responsiblity. Can a midwife do that by advising women but leaving all responsibility for her care on her shoulders, as Joy explained some homebirth midwives in the USA do, above?
Also, in their view, nutrition is a preventative measure, elevated blood pressure late in pregnancy is normal, it's normal to spill a bit of protein, it's normal to get hormonally-driven headaches. Who are you to tell them they're wrong?
From Yehudit:
In particular I think we should be able to rule out using pseudoscience as a way of managing medical conditions.
++++++++++
Granted for a definition geared towards protection of women today, but not if we are talking about an "essential definition" - because midwives existed before modern science, and I'll be damned if I'm going to say that Shifra and Puah were not midwives. That doesn't mean that if they teleported to upstate New York today that they get a license to practice, you understand.
As for who gets to decide about what constitutes preventative and other similar questions - ultimately, it is the state that arbitrates by recognizing some qualifications, some professional bodies, some regulatory systems and not others.
From Caryn:
Best scientific practice was different then. It's dynamic.
From Yehudit:
Their neonatal care was to not arrive until after the baby had already been born (or at least their documentation of births was very suspect). And all because they feared God. (Exodus 1:17-19)
From Emilia Liz:
It's interesting, Dr. Amy, that you call the Palestinians homophobic and misogynistic yet you condemn single and gay parents on your other website. That's kind of like Pablo Escobar calling Arkan a criminal or vice versa.
From Emilia Liz:
Dr. Amy,
Since you claim to be so scientific, what do you make of this study about single mothers by choice?
Solo mothers and their donor insemination infants: follow-up at age 2 years
C. Murray 1* and S. Golombok 1
1 Family and Child Psychology Research Centre, City University, Northampton Square, London EC1V OHB, UK
Abstract
BACKGROUND: Findings are presented of the second phase of a longitudinal study of solo-mother families created through donor insemination (DI). METHODS: At the time of the child's second birthday, 21 solo DI mother families were compared with 46 married DI families on standardized interview and questionnaire measures of the psychological well being of the mothers, mother-child relationships and the psychological development of the child. RESULTS: The solo DI mothers showed greater pleasure in their child and lower levels of anger accompanied by a perception of their child as less ‘clingy’. Fewer emotional and behavioural difficulties were shown by children of solo than married DI mothers. CONCLUSIONS: The findings from this first cohort of solo DI families to be studied lend further weight to the view that these women represent a distinct subgroup of single parents, who, out of a strong desire for a child, have made the active choice to go it alone. Moreover, this route to parenthood does not necessarily seem to have an adverse effect on mothers' parenting ability or the psychological adjustment of the child.
From Caryn:
Even the ACNM recognizes lay midwives as midwives.
Not any more, I see.
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