Monday, January 21, 2008

Midwifery

An article was published in the St. Louis Post-Dispatch about midwives, which are illegal in Missouri. Well, in a way.

After almost 20 years of legislative debate, midwifery was legalized in Missouri last summer, when Sen. John Loudon, R-Chesterfield, inserted a vague clause into a larger bill. A circuit county judge, however, ruled that legislative procedures were not followed and struck down the law, which has been sent to the Missouri Supreme Court on appeal.

Whatever the outcome, midwife advocates and doctors promise another showdown this legislative session over a more comprehensive bill that would license and regulate midwives.
What form would this licensure take? This article is pushing midwifery as a "health freedom" and "female empowerment" issue, but by using a midwife rather than a doctor you're essentially allowing someone with no medical training to perform medicine. No license can fix that.

Midwifery is a tradition that goes back centuries, whereby women support each other through pregnancy, birth and early infancy. Much of that tradition was born out of necessity, when there were few doctors and even fewer hospitals.
Now that the necessity has lifted, when everyone can have access to a trained doctor in a hospital, why does this practice continue?

A few statistics on the sidebar of the article provide a bit of evidence about the safety of midwife births relative to hospital births. For instance, "Infant death rate was 1.7 per 1,000, consistent with low-risk births at hospitals." Is this the low-risk death rate or the overall death rate? And how does a midwife assess risk, given that they monitored the fetal heart rate in less than ten percent of cases?
Medical intervention rates for planned home births with midwives were consistently less than those of low-risk births in hospital.
I should hope so! Again, midwives have no formal medical training. Yet despite this fact, they perform episiotomies and C-sections in 2.1 and 3.7 percent of cases, respectively. That's surgery!

And why is it a virtue to minimize intervention? I would much rather have a professional intervene in the birth of my child if it was recommended to me than to refuse that intervention or, worse yet, never have it recommended in the first place.
While 99 percent of all births in the U.S. occur in hospitals, states need to recognize that some parents are going to choose home birth, said Katie Prown, a midwife advocate who helped draft legislation that legalized midwifery in Wisconsin and Virginia. "So what can we do to make it safe?"
Either train the midwives in actual medicine or incentivize real doctors to perform home births.

In fact...
Doctors say a system already exists for women to have a home birth in Missouri and Illinois: Midwives with a nursing degrees. But non-nurse midwives say they only want training in pregnancy and home birth, not nursing degrees with hospital training.
Tough. You've got to walk before you can run, and basic medicine will, hopefully, give you the skills you need to keep patients alive.

My favorite quote comes from a doctor, who doesn't buy the "freedome of choice" argument.
While there are few other options for non-hospital births, direct-entry [aka untrained, non-nursing-or-medical degreed] midwives shouldn't be allowed to practice just so that a mother can have a child at home, said Goldman, an obstetrician for the past 33 years.

"So what should we do? Dumb down the process so you have a choice?" he said. "What about the fetus' choice?"
I guess sometimes empowerment and the myth of "natural births" trump the safety of a newborn child.

- Thanks to Bing at Happy Jihad's House of Pancakes for the link. He's got a lot more there about this story and others related to it.

27 comments:

Midhusband said...

Greetings Gateway Skepticism,

As a guy whose been putting nuclear reactor cores together for 20 years, I must say I am a little disappointed that graduate students in physics would form an opinion based solely on, what appears to be, conventional thinking.

I suggest you turn your skepticism toward the current medical model of childbirth. Do ya really think 1 in 3 women undergoing abdominal surgery to extract the fetus is consistent with optimal safety?

The right way to do safety analysis is to count all defects and understand all failure modes. It is typical to focus on the thing that is easy to count – bad outcomes for the baby. Today we know that planned home birth with a Certified Professional Midwife enjoys outcomes that are indifferent to hospital for low risk women with a 5x reduction in C-section (~4% vs. ~20%)…but there’s more to it. We know there is a dramatic increase in hysterectomy with C/S (conceptually a lost opportunity dead baby). It is believed, although there are conflicting studies on this, that there is increased miscarriage with C/S (simply put, a dead baby). Furthermore, maternal mortality is increased with C/S, albeit the absolute probability is lower than that for the baby.

The right way to do safety analysis is to count all defects (mortality and morbidity), consider the probabilities and combine with importance weighting to judge safety. In so doing, you will find that planned home birth with a CPM is arguably safer than hospital birth. This is because the midwives are trained to recognize when complications are on the rise and these complications tend not to be catastrophic in terms of time to intervention.

I understand why most people would think that close proximity to advanced obstetrical problem solving should have a safety advantage, but I would expect more thoughtful consideration from physicists.

In terms of the remarks related to the midwives having no medical training, you are decidedly wrong here (although the practice of midwifery is not the practice of medicine even though there is some overlap). The midwives are trained on a catalog of skills the midwife must master to maintain safety and they emulate a mobile primary care facility. Their proficiency is assured via examination and the CPM program is accredited by the same organizations that accredit the CNM program.

Class is in session. I’m hoping this ill-considered post was simply a homework assignment as if it were a final examination I fear you would not pass.

Russ

Bing said...

Oh, Christ. A midwife-man is building nuclear reactors. We're fucked.

HJ

Flavin said...

Midhusband,

Thank you for your frank appraisal. I did presumably base my loosely-held opinion on conventional thinking, because I'm not really sure what the conventions are. Given evidence one way or the other, I can easily be swayed on this issue.

I suggest you turn your skepticism toward the current medical model of childbirth. Do ya really think 1 in 3 women undergoing abdominal surgery to extract the fetus is consistent with optimal safety?

No, I'm not. Nor am I sure that number is accurate, as you haven't cited it. The article I linked did say 33% of hospital births involved episiotomies, but can this be accurately described as "abdominal surgery?" Plus, they didn't cite their number either.

We know there is a dramatic increase in hysterectomy with C/S (conceptually a lost opportunity dead baby). It is believed, although there are conflicting studies on this, that there is increased miscarriage with C/S (simply put, a dead baby). Furthermore, maternal mortality is increased with C/S, albeit the absolute probability is lower than that for the baby.

The right way to do safety analysis is to count all defects (mortality and morbidity), consider the probabilities and combine with importance weighting to judge safety. In so doing, you will find that planned home birth with a CPM is arguably safer than hospital birth. This is because the midwives are trained to recognize when complications are on the rise and these complications tend not to be catastrophic in terms of time to intervention.

I can't accept any of these statements as facts because they're unsourced. After a link or reference is provided we can go from there, and I'd like nothing more than to do that. However, as of now, these are little more than anecdotes.

In terms of the remarks related to the midwives having no medical training, you are decidedly wrong here (although the practice of midwifery is not the practice of medicine even though there is some overlap).

My point is that it should be medicine. I'll give an analogy. Chiropractors also have years of training and have to be certified. Does that mean they should be allowed to control a life-and-death situation? What about one involving a child?

Being trained to "maintain safety" only means they won't be directly responsible for bad outcomes, and can prevent some emergencies. However, when the primary means of dealing with problems is to refer a patient to a doctor, I ask why they weren't with a doctor in the first place.

Again, I appreciate the input. If you'd like to come back with supporting evidence for your claims, I reserve the right to be completely swayed from my opinion and onto your side. However, keep the condescension at home. We really don't need it here.

Midhusband said...

Greetings Again, Flavin,

First of all, please call me Russ. I will respond to your thoughts below, but in advance of that, let me address the hard feelings. I used a heavy hand as your original post was filled with technocratic arrogance (coming from a technocrat). Please review your words and imagine how a home birthing father, a midwife’s spouse and reactor physicist might react. Were you to walk a mile in my moccasins, you would readily conclude that maternity care is broken in the US.

While blogs inherently tend to lob barbed wire covered marshmallows to stimulate discussion, have a care with your words unless you are convinced you are correct.

Russ

“Midhusband,

Thank you for your frank appraisal. I did presumably base my loosely-held opinion on conventional thinking, because I'm not really sure what the conventions are. Given evidence one way or the other, I can easily be swayed on this issue.”

References are provided below. Always remember, Google is your friend.

“No, I'm not. Nor am I sure that number is accurate, as you haven't cited it. The article I linked did say 33% of hospital births involved episiotomies, but can this be accurately described as "abdominal surgery?" Plus, they didn't cite their number either.”

The national average C/S rate was 31.1% in 2007. This can be confirmed at the CDC web-site. In terms of the appreciating the issues we face, you should understand that the environment is such that once a C/S (almost) always a C/S. It is difficult to measure the impact on mothers and babies, but everyone should be worried about it. This shocking C/S rate is due in large part to defensive medicine and fear of litigation. Today, Plaintiff’s Attorney has more influence on obstetrical standards of care than evidence (just ask your friendly neighborhood OB).

“I can't accept any of these statements as facts because they're unsourced. After a link or reference is provided we can go from there, and I'd like nothing more than to do that. However, as of now, these are little more than anecdotes.”

A recent study on the frequency of hysterectomy associated with C/S was prepared by Knight, et. al. “Cesarean Delivery and Peripartum Delivery”. This study concluded the following probabilities of hysterectomy:

P(vaginal delivery) = 1/30,000
P(1 C/S) = 1/1700
P(2 C/S) = 1/1300
P(3 C/S) = 1/220

These probabilities are significant in light of the probability of a bad (intrapartum+neonatal) outcome for planned home birth of 1.7/1000 (and indifferent to hospital birth). I suggest reading Johnson & Daviss’ study “Outcomes of Planned Home Birth with a Certified Professional Midwife, Large Prospective Study”.

“My point is that it should be medicine. I'll give an analogy. Chiropractors also have years of training and have to be certified. Does that mean they should be allowed to control a life-and-death situation? What about one involving a child?”

Wrong! Medicine is problem solving. Midwifery is focused on maternal health and preventing problems. In my state, the excess bad outcomes (for the baby) are primarily associated with poor maternal health and poor access to maternity care (as described by the Perinatal Period of Risk methodology). Confining women to the hospital is not the solution to our problems. Improving maternal health and access to care is the solution.

“Being trained to "maintain safety" only means they won't be directly responsible for bad outcomes, and can prevent some emergencies. However, when the primary means of dealing with problems is to refer a patient to a doctor, I ask why they weren't with a doctor in the first place.”

First of all, I celebrate and applaud our ability to solve obstetrical problems and all of the women and men working hard in the service of families. Obstetrics is part of the safety of all birth models. At the same time, excessive application of interventions degrades safety. Your argument above is a copout. If you review Johnson & Daviss’ study, you will find that a number of the bad outcomes assigned to the home birth group can be assigned to the hospital. Nevertheless, we accept the data.

“Again, I appreciate the input. If you'd like to come back with supporting evidence for your claims, I reserve the right to be completely swayed from my opinion and onto your side. However, keep the condescension at home. We really don't need it here.”

Evidence has been supplied above. I truly hope you will objectively reconsider your position in the original post (again, I suggest you reread what you crafted). Quite frankly, I was being pretty nice compared to what women must endure who make a different choice than that considered normal. Imagine for a minute the millions of women who have endured an episiotomy that we now know is not helpful (an episiotomy is a surgical cut from the base of the vagina toward the rectum). What score shall we give these in the bucket we label morbidity?

Russ

Midhusband said...

Greetings Bing/HJ,

My hat is off to you. Your post was absolutely brilliant.

I hope you will find in your heart a little sympathy for this silly old Midhusband, and not be too hard on me. I have many personal limitations, but I give you my promise to maintain the quality standards required to assure safety of our nuclear power plants (and to do my part to address Global Climate Change at the same time).

Yours,

Russ

Carolyn McIntosh said...

Another anecdote perhaps.
In the area of public transportation there are buses trains and airplanes (amongst other things). All are driven by people trained to do the job. A bus driver or a train driver would never dream of flying a plane however a pilot might just consider he can drive a bus or a train. None the less he is no more trained to do so than you or I it is a completely different area of expertise. In all of these professions the lives of the public are in their hands and we presume that all will have the expertise in their own fields to do the job required of them, both in the normal course of events and in the very unlikely possibilities of an emergency situation occurring.

What authority claims that childbirth is part of the field of medicine? It is a normal part of human existence. Birth is not an illness (see the world health organisation "Care in Normal Birth: report of a technical working group
1997 - WHO/FRH/MSM/96.24")

Why do you think that surgeons should have overwhelming control of this natural process. This is no more logical than an airline pilot driving a bus or a train. Obstetric control of childbirth puts the health and wellbeing (and lives) of mothers and children at risk.

Ben said...

Carolyn,

I think the difference is that a medical doctor or surgeon can and would help if something were to go wrong. While the pilot may not know the controls of the bus or the train, the physician does know the human body and how to attend to crises.

Also, just because something is natural does not mean it would not benefit from medical expertise. The mortality rate of infants and mothers have both been improved drastically by modern medicine.

Carolyn McIntosh said...

I could ask you for your evidence that maternal and child health have been improved dramatically by modern medicine, as you asked Russ for evidence. However, a bit like the bible, we would then get into a battle of who has the best evidence, and I am afraid I just do not have the time fr this at the moment. The problem is that when you take this normal and natural event and impose medical rules on it you change it so drastically that it is no longer normal and natural.

We have no idea what the longterm outcomes for society will be of the interventions we currently impose on birth. This is a huge uncontrolled scientific experiment without adequate controls or data gathering. No one knows what the longterm sequellae will be.

Flavin said...

Carolyn,

Please read this before continuing the discussion. Just because something is natural does not mean it is good. Clothes, air conditioning/heating, and farming are not natural: they are all invented technologies and they all prevent death. Well, clothes less so, but presumably they once did.

And it's hard to find a source directly saying that medical intervention reduces mortality over no medicine at all. To be frank, it's so obvious that I don't think anyone bothers to say it. However, I did find a nice graph I think demonstrates the point. It doesn't come out and say that medical intervention caused the dramatic decline in mortality, and in fact there were probably many factors. However, given that births were managed by doctors at the time, I'd say a causal link has been established by historical knowledge. Also, the graph is presumably only for America, which is a drawback.

Your claim is surprising because even midwives benefit from the knowledge of the body, preventing disease, and nutrition gained from scientific medicine.

Russ,

Let me assure you that through your comments my perspective on this issue has been enriched. For archival purposes I won't change my article, but hopefully this and other comments will serve to nuance my position. And please take my opinions with a grain of salt; medicine is not my field of expertise.

I concede that properly trained midwife delivering a baby in the home or other setting does seem to be a fine alternative to a hospital birth in some cases. How many cases, we don't currently know. While the Johnson and Daviss study you referenced does provide evidence for the safety of births overseen by midwives, only mothers who had self-selected to use a midwife were examined. The authors of the study admit this shortcoming:
A randomised controlled trial would be the best way to tackle selection bias of mothers who plan a home birth, but a randomised controlled trial in North America is unfeasible given that even in Britain, where home birth has been an incorporated part of the healthcare system for some time, and where cooperation is more feasible, a pilot study failed.

So while I admit that there is a case to be made for allowing the choice of a midwife-overseen pregnancy and birth, I still have concerns.

1. How much training is necessary?
Certified Professional Midwives are not required to have a bachelor's degree or even a high-school diploma. However, Nurse Midwives are moving towards more education. I quote from this FAQ:
In terms of education, while in the past a baccalaureate degree was not required to become a CNM, the trend is toward requiring this degree, and moving toward requiring a Masters Degree. For example, even now to practice as a CNM in Oregon, you must have a Bachelors Degree, even if you already got your CNM credential without that degree. The American College of Nurse Midwives has made it quite clear that they are moving toward all their midwife programs eventually requiring a Masters; they are already phasing out programs that did not require a Bachelors.
Why is it that one standard for midwives has no minimum education requirement, but the other standard is increasing their minimum? I don't want to draw any conclusions from a lack of data, so I will ask for references if you have them or hope for a study to be conducted if you don't. How much education should be required for certification in the practice of midwifery?

2. The push against technical intervention.
Since you cite statistics on the probability of hysterectomy given various numbers of C-sections, I'll use them as the example, but the same argument could serve for other interventions.

While I admit these numbers are troubling, I do not think they bear on our discussion. If the practice of C-section is less safe than previously accepted, then this needs to be taken into account when considering the necessity of the procedure. However, making a point of ideology out of avoiding a procedure is not the answer. If part of the philosophy of midwife organizations is to "minimize technical interventions," the danger is that steps will not be taken to intervene when it is necessary. An unperformed necessary C-section would certainly lead to significant morbidity and mortality (which is how I'm defining "necessary"), while an unnecessary C-section increases risks of complications, possibly leading to death, and hysterectomy. Both should be kept to the absolute minimum. However, obstetricians do not include in their model of care the goal of performing as many C-sections as possible, while midwives do include in theirs to perform as few as possible.

To minimize technical interventions is no virtue, unless it is specifically stated to minimize interventions to only those necessary. Minimizing the absolute number invites misappraisals of the necessity of an intervention.

Ben said...

I have not talked to Russ...

Surely you do not disagree that anesthetics, drugs, emergency surgeries, ultrasounds, and the myriad other improvements in medical technique and hygiene (I consider all those aspects of modern medicine.) have helped decrease the infant mortality rates. That would be quite an astounding thing to deny. If so, I would like to know where your distrust of modern medicine is coming from.

Midhusband said...

Greetings Ben,

Let me extend upon Carolyn’s analogies which were very well put together. Another way to look at this is to ask “Would you rather have an electrician wire your house or an electrical engineer?”. Now I love engineers, but quite frankly there is a lot of craftsmanship involved in construction and the ability to solve differential equations is not particularly relevant to construction. Connecting the dots with childbirth and midwifery, the midwives are focused on promoting health and invest a tremendous amount of time achieving this. If complications arise, they are trained to recognize this and transfer care. Physicians are schooled in problem solving (although some clearly have great midwifery skills).

How many people spend 15 minutes with their physician, receive advice that “you should exercise more and eat better” and actually respond? I suspect the personal trainer who says “I’m gonna meet you in the gym at 5:00 am and we’re gonna have a great workout”, will show better results. Sometimes we need problem solvers, but the problem solvers have taken over and health has suffered.

On your specific remarks…

“I think the difference is that a medical doctor or surgeon can and would help if something were to go wrong. While the pilot may not know the controls of the bus or the train, the physician does know the human body and how to attend to crises.”

The vast majority of births are uncomplicated. Interventions tend to result in a cascade of interventions with a variety of risks, failure modes and defects. Surgeons are trained in surgery, and I suspect that most enjoy their work. It is interesting to note that C-sections are most likely to occur around 4:00 pm (let’s get home for dinner) and 10:00 pm (let’s avoid staying up all night). Considering the probability of excess hysterectomy with C/S, it is clear a lot of women have lost their fertility in an effort to manage schedules. The midwives attend the woman for as long as it takes.

“Also, just because something is natural does not mean it would not benefit from medical expertise. The mortality rate of infants and mothers have both been improved drastically by modern medicine.”

Actually, the things that have most improved perinatal mortality (a better measurement than infant mortality) are nutrition, anit-biotics, blood transfusions and anti-hemorrhagic medications. While advanced problem solving does save lives, and the obstetrical technologists have gotten darn good at it, I again remind you that 1 in 3 women undergoing abdominal surgery to greet their child is madness. Furthermore, I remind you that outcomes for low risk women birthing at home with a skilled midwife are indifferent to hospital, with a dramatic reduction in interventions (and low birth weight babies) and is therefore safer.

Russ

Bing said...

Russ,

I will be nice to the guy who's playing with the radioactive materials!

HJ

Bing said...

When the delivery is botched by a midwife and is rushed to the hospital and it has a bad outcome, do you put that in the hospital column or the midwife column?

HJ

Ben said...

Thanks for your response Russ. The analogy still doesn't seem quite right to me, but I can't think of anything new to say about it. I would have to know more about how physicians are trained to add anything more insightful.

As for anit-biotics, blood transfusions and anti-hemorrhagic medications, I do believe those are part of modern medicine.

I am not making any judgments on midwifery because, quite frankly, I don't know enough about it. It just seemed like modern medicine was being shrugged off an awful lot.

Carolyn McIntosh said...

Gentlemen please check this document before commenting further. Particularly page 4. As Russ said over 30% of women in the US are birthing by Caesarean section. The world health organisation claims that in any population no more than 15 of women should require this level of intervention. therefore women and children are being put at double the risk of serious morbidity through the medicalisation of childbirth. Is society prepared to continue to accept this ever increasing level of intervention?

Carolyn McIntosh said...

Sorry didn't put link. here it is http://www.nice.org.uk/guidance/index.jsp?action=download&o=29333

Carolyn McIntosh said...

You are correct that midwifery is a discipline which requires a course of study and clear scope of practice. In New Zealand midwifery education is primarily through a 3 year direct entry Bachelor's Degree program. Yes, midwives need to be aware of evidence about birth and require certain medical skills to be able to care for women. Midwives need to have skills in assessing well being of the mother and child resuscitation of the mother and child, intravenous canulation and venepuncture and suturing amongst many other skills. In New Zealand midwives are also able to prescribe within their scope of practice and need knowledge of pharmacokinetics and pharmacodynamics as they relate to women during the childbearing year and the newborn.

So midwives use all these skills of modern medicine but do so from the perspective of pregnancy and birth being a normal physiological process which works best in an environment condusive to allowing the woman's body do the job it needs to do. None the less midwives need to be continually vigilant and aware ready to intervene and perform emergency measures if necessary while referring on to specialist medical care when the need arises.

If the midwifery profession is licensed then legislation can regulate the education and continuing professional development requirements of the profession. this is a much better situation than ignoring the desires of women to have a midwifery service and driving the profession underground.

Flavin said...

Carolyn,

I agree. Having a licensure for midwives in which they become qualified to practice medicine is a great thing.

Part of the motivation for this article in the first place was a law that allowed midwives to practice who had obtained certification at a much lower standard than you describe. I think that is at the heart of the issue. If a person is, as I may have naïvely done, criticising midwives as a whole, that person is committing a hasty generalization. There are standards for midwives in many states in the US that require at least a bachelor's if not a master's degree, and the evidence I've seen says those standards can and do enforce a level of professionalism and care that actually works to keep people safe.

Midhusband said...

Greetings Ben and Flavin,

I’m pretty happy with the state of the discussion at this point.

I have spent over 20 years on airplanes, soccer fields and pubs talking about how nuclear power can be considered the most environmentally benign form of electricity production we have, and I don’t think I have convinced very many people. So I am really not trying to convince anyone that planned home birth with a skilled midwife can be considered safer than our current model of hospital birth. I’m not trying tell anyone how they need to give birth.

What you should conclude from Johnson and Daviss’ study is that planned home birth with a CPM is absolutely a valid choice. You would find the number of health care professionals working on Labor and Delivery wards booking home births with CPMs remarkable. We know today that the CPM requirements for certification, standards of care and training are perfectly fine when we measure outcomes, morbidity and mother’s satisfaction with the quality of care. Our objective should be to improve access to care and integrate them into the health care portfolio to manage a transfer of care. These objectives are consistent with maximizing safety and improving maternal health.

On the specific points…

“1. How much training is necessary?
Certified Professional Midwives are not required to have a bachelor's degree or even a high-school diploma. However, Nurse Midwives are moving towards more education.”

The CPM is accredited by the same agency that accredits the CNM program (NOCA/NCCA). The CPM certification is granted after 1) demonstrating proficiency in the required skills, 2) meeting the clinical requirements, 3) passing the comprehensive written examination and 4) passing the skills examination. If you perform a gap analysis focused on clinical skills training, you conclude the CNMs and the CPMs are largely equivalent. Yet the CPM is the only health care professional explicitly trained in the home setting. The Portfolio Evaluation Process is equivalent to ~1300 hrs of classroom training. The CPM is licensed in 22 states and the trend is very positive, indeed it is inevitable in all states, but the legislative process is decidedly inefficient.

“2. The push against technical intervention.
Since you cite statistics on the probability of hysterectomy given various numbers of C-sections, I'll use them as the example, but the same argument could serve for other interventions.

While I admit these numbers are troubling, I do not think they bear on our discussion. If the practice of C-section is less safe than previously accepted, then this needs to be taken into account when considering the necessity of the procedure. However, making a point of ideology out of avoiding a procedure is not the answer.”

One way to look at this is that there are lots of women in which having an intervention free birth is important (this may be hard for men to understand prior to fathering – at least it was for me). For those women, having access to a care provider who will support them, yet keep them safe, is of critical importance. If you take a long term interest in this subject, you will find a great body of thinking that says this epidemic of C/S, and medicalized birth, is shocking.

“Part of the motivation for this article in the first place was a law that allowed midwives to practice who had obtained certification at a much lower standard than you describe.”

Again, the focus of the CPM program is to assure the clinical skills are adequate along with an understanding of the basis for the skills. While a BS is not required, I think we can all agree that understanding whether the carbon atoms in pitocin are SP2 or SP3 hybridized such that the molecular geometry can be inferred, something you might learn in O-chem, is entirely irrelevant to safely administering it to address maternal hemorrhage. I can teach anyone with a keen wit how to put a core together as you don’t need to be able to numerically solve the neutron transport equation to do so – we have sophisticated computational engines to do that. What I have observed is that the CPMs have a tremendous passion for supporting women with childbirth and work tirelessly to maintain safety.

Hi HJ –

Thanks for cuttin’ me a break. In response to your question on epidemiological practice…

“When the delivery is botched by a midwife and is rushed to the hospital and it has a bad outcome, do you put that in the hospital column or the midwife column?”

If you read J&D’s study that Flavin linked to above, you will find that the bad outcomes following a transport to the hospital are assigned to the home birth group. Each bad outcome was investigated to try and understand the root cause. If you invest the time to read it, you will also conclude that it is difficult to assign the bad outcomes to the setting or the care provider. The key take-away is that it is very difficult to conclude there is a difference in outcomes between planned home birth with a CPM and planned hospital birth.

Hope that helps,

Russ

p.s. For fans of The Simpsons, like me, I should point out that irradiated nuclear fuel glows blue and not green.

Ben said...

Next, you're going to tell me that exposure won't turn me into a mutant or superhero. I don't know if I can take the shattering of any more of my world.

Carolyn McIntosh said...

Ok I am going to bow out graciously now. One final thing. A thought from me. Why could you not establish a direct entry degree program for midwives. Midwives currently working as CPMs could be given a time frame in which to gain this qualification while continuing to have temporary licensure. They could be given recognition of prior learning for all of their knowledge and experience where they can demonstrate this and so acquiring the degree should not take too long or be too arduous.

I understand that those opposed to any control on the profession will most likely be opposed to such a move.

Midhusband said...

Hey Miss Carolyn,

The CPM in the US is the culmination of the Direct Entry Midwives. Since the 1970’s, DEMs have been licensed with each state establishing its own standards. In the late 1980s and early 1990s, a congress of professionals was convened to establish the requirements necessary to be certified as midwife. This resulted in the CPM credential. We simply need to recognize this (we are a little slow).

It has been a pleasure hearing your thoughts.

Russ

Midhusband said...

Hey Ben,

I'm still hoping for that Superhero transformation. Alas, these days, I mostly write e-mails and make presentations and am not exposed to ionizing radiation (the thing that makes this a living planet). At the same time, a little bit of shielding (e.g. water) prevents significant exposure and so I haven't received that much dose even though I used to perform pool-side surveillance on irradiated fuel when I was a youngster.

Russ

Ben said...

Hey Russ,

Now you're talking about a topic I know a thing or two about, being a physics graduate student. I think my readings into the history of the discovery of radioactivity taught me that the kind of mutations one gets from that stuff is not one I would want anyway. I guess agonizing death by radiation poisoning is not really much of a superpower.

Flavin said...

Before this conversation goes any further, I think we all need to remember the previous post.

Ben said...

There is nothing on the vertical axis. I don't have to pay attention to it.

Sarah Stewart said...

Thank you for a very interesting column and conversation. As Carolyn said, I do not have the time to follow this up with a load of references etc, but suffice to say, there is plenty out there to support the safety and effectiveness of midwifery practice and also to show rising C/S rates as well as ongoing problems with them. You just need to looking established medical literature. cheers Sarah