Midwifery: March 2003 Archives

Hormone Disrupters


I've mentioned this before, but thanks to Victor Lams at et cetera for finding the link. Hormone Disrupters in our water supply - and this about Chemicals affecting women and girls. What are we doing to ourselves? God gave us stewardship of the earth - not to worship it, but not to rape it either. St. Francis, help us to learn how to worship God and care for His creation!

The end of pregnancy


whether ended by birth, miscarriage, or induced abortion, is inevitably accompanied by a maelstrom of feelings. A feeling that is not often acknowledged, especially in cases of the birth of a loved and wanted child, is grief. This feeling is also not often acknowledged in cases of induced abortion.
Grief is a feeling, and grieving is a process. Grief arises out of loss. When pregnancy ends with birth, one grieves the loss of the pregnancy, the loss of the dream baby (and confrontation with the real baby!), the loss of the dream labor. One is faced with bodily changes that may be rather devastating - aches and pains and loss of sleep, practical problems finding clothing that is wearable let alone attractive, and a host of other unforseen issues. Moms and dads can be overwhelmed with feelings that they judge as negative or unacceptable - anger, disappointment, apathy, hysteria - or can even experience serious depression.
It is not often acknowledged that this maelstrom of feelings can also be energizing. Out of some mothers' grief and anger have come many movements to help the next generation of mothers. Such movements include La Leche League, ICAN (cesarean awareness and VBAC), various childbirth education and preparation groups, and the movements for Baby Friendly and Mother Friendly birth places.
After miscarriage or stillbirth, these feelings are also present. For many years, women kept these griefs private. But a few women were energized enough by their grief to reach out to other grieving women and families, and through their persistence, most hospitals now give more support and and affirmation to all women suffering this kind of loss.
I think that we are just now beginning to see the foundation of a movement that will support the grief and loss experienced by those who intentionally aborted pregnancies. Rachel's Vineyard, Ashli's S.I.C.L.E. blog, and various post-abortion services have sprung up to help.
In the early days of other grief supprt movements, there were those who nay-said the women and men who were reaching out to try to change things. This is also happening with the pro-life post-abortion support services. Hang in there, sisters and brothers. It will be a long struggle, but eventually you will earn a small modicum of respect, even from your opponents. Hald fast to the truth of what you know, and just keep loving the women and men who are suffering in silence.

Pregnancy Issues


I started to post a comment over at the Kairos Guy and realized that I would exceed the box's limits, so I am posting it here. You see, J.B. included some comments in his post about pregnancy, a topic on which I do know a little bit. Here is an excerpt from his much longer post (J.B., I hope you don't mind that I have truncated your writing - there is a lot of stuff there and I only want to address a few small points!).
Last summer, one of the pregnancy issues before us was the possibility that Mrs. Kairos Guy had a tubal pregnancy (which turned out not in fact to be the case). Now, I have no essential qualms with the Church's ban on abortion: it is fundamentally sound, and I support it. In fact, "support" is much too weak a verb to describe my attitude. I believe it to be True.[You're waiting for me to say "but," aren't you?]But. I learned, after the fact, and after consulting a couple of people on my cell phone standing outside the Emergency Room but getting only partially correct information, that even though a fetus implanted in a tube cannot live, and a mother who allows that fetus to continue gestating will certainly die, it is not licit for that woman to have an abortion. What IS licit is the removal of the entire fallopian tube in which the fetus is implanted, even though that too means the death of the fetus. At that point, we all get to pretend that the unburst tube is the problem, rather than the fetus, and we maintain the fiction that we did not seek nor receive an abortion, but that the death was the result of a "double effect." (I hasten to remind you again: there was not in fact a tubal pregnancy in our case). But it requires a great deal of fooling oneself to pretend that the only thing going on with the tubectomy was the treatment of the tube, and not the removal of the fetus before the fetus kills the mother. (As it happens, recent studies have suggested that there are medical benefits to a tubectomy not present in the "Dilation and Evacuation" procedure that is common for most women. The scarring of the tube that a D&E can cause greatly increases the chances of further ectopic pregnancies and miscarriages. With a single tube, unscarred, pregnancy remains eminently possible, with little increased risk.
Let me recommend a resource for information on Catholic Bioethics. This center will answer questions by email. Also, the Pope Paul VI Institute, directed by Dr. Thomas Hilgers at Creighton University has a center for reproductive bioethics. Now for my comments.
I will be using mostly medical terminology . Embryo is a baby in the first trimester of pregnancy, fetus is the baby thereafter. By using these terms, I do not mean to imply any diminuation of the humanity or right to life of that child! Ectopic means not in the right spot, in medical terminology. Things other than pregnancies can be ectopic (like heartbeats). The most common kind of ectopic pregnancy is in the Fallopian tube. Rarely, a pregnancy will implant in other places outside the uterus. Such abdominal pregnancies can be carried to viability or even to term, and although abdominal surgery (laparotomy, not Cesarean as the uterus is not entered) is required for delivery, there have been multiple cases reported in the medical literature. It does carry an increased risk to the mother's health, depending on where the placenta implants. There have even been some pregnancies reported after hysterectomy, probably where conception occured but was not known before the surgery was done. At least one of these babies survived to be born healthy. Before ultrasound, we had no way to know for sure where and sometimes even if there was an ectopic pregnancy, and prudent physicians hesitated to subject mothers to possibly unneeded surgery, but also faced the spector of missing the diagnosis of ruptured tubal pregnancy until the mother was in extremis. 30 years ago, a friend of mine was clerking in a law office preparing a suit on just such a missed diagnosis that ended in a maternal death. So we who work with women in their childbearing years are hyper vigilant. Thankfully we have tools now that have made diagnosis of tubal and other ectopic pregnancies much easier and quicker.
It is generally believed that tubal pregnancies will inevitably end in the rupture of the tube and loss of the baby. This may not always be the case, as there is a theory that at least some abdominal pregnancies started out as tubal pregnancies but the embryo was expelled out the end of the tube into the abdomen. No one knows, and no one will probabaly ever find out, because now that we have the tools to watch, we intervene early to prevent this. The standard treatment for tubal pregnancy is to end the pregnancy as soon as the diagnosis is comfirmed. The Catholic teaching is and continues to be that removing the tube is licit, even though that will also abort (technical definition - end prematurely, cause untimely death) the pregnancy. The tube is damaged - at least that section of the tube containing the embryo. I know of at least one physician (Dr. Hilgers) who will attempt to place the embryo from the tube into the uterus when doing microsurgery for tubal pregnancy. I don't know if he has had any successes, but as a committed Catholic physician he believes that he has that duty to at least try to give the baby a chance. I am not sure that the principle of the double effect requires that the tube actually rupture or just that it be certain that the tube is damaged. I will defer that to a professional ethicist. What I do know is that the medical (non-surgical) treatment for tubal pregnancy is not morally licit. This treatment involves injecting the woman with a drug (usually methotrexate) that has the effect of directly killing the embryonic life, and thereby preventing further growth that could cause the tube to rupture. This technique is quite similar to early induced abortions done with RU-486.
Dilatation and Evacuation (D&E) or Dilitation and Curettage (D&C) have NO place in the treatment of ectopic pregnancy. These procedures are used to empty the uterus with vacuum (Evacuation) or scraping tools (Curettage). They are used both to complete a miscarriage (spontaneous abortion) where there is excessive bleeding or parts of the baby and placenta are not expelled naturally, as well as to perform induced abortions. Any time the uterus is instrumented, there is a risk of infection or physical damage, and infected tubes are more likely to get scarred and therefore more likely to not transport the embryo to the uterus in the timely manner required to implant properly.
Ectopic and tubal pregnancies have become epidemic in our society. There are many totally blameless women who have suffered the agony of a tubal pregnancy. However, the risk of a tubal pregnancy is known to be higher in women in the following categories - women who have had pelvic infections (usually from sexually transmitted diseases, occasionally from such conditions as a ruptured appendix or other abdominal infection causing scars), women with endometriosis, women who have had tubal ligations (even after reversal surgery), women who get pregnant while using an IUD, Depo-provera, other hormonal contraception. (the hormones make the tubes slower at moving the embyro down to the uterus, and they also make the lining of the uterus less hospitable).
I realize this is a lot of info, and I don't mean to slight anyone or anything here. Please feel free to correct me if I have anything wrong, or to ask for clarification if I have been fuzzy in my speech.

Safe Haven Laws


Safe Haven Laws - are they unsafe?
This is a topic about which I have some conflicted feelings. New Hampshire recently passed such a law. On one hand, I hope never to hear another baby in the dumpster story. On the other hand, I would hope that women would face up to the fact of their pregnancies and take good care of the baby before birth.

This is not the carefully crafted piece I am still working on, but rather is a few random comments. I have a good friend in Portland Oregon who has been a midwife for more than 20 years. She has been published in Midwifery Today, she organizes continuing education workshops for midwives, she is truly knowledgeable and skilled in her profession. And she is not licensed. She practices perfectly legally in her state. There was a court decision several years ago in Oregon that stated the practice of midwifery is not the practice of medicine, as long as the midwife does not use interventions that are considered medical (such as drugs including pitocin, surgery, forceps or vacuum, etc.). Herbs, physical interventions using the hands, etc. are not considered medical, nor is cutting the cord. There are no standards that exclude any kind of patient from the midwife's practice, other than personal choice on the part of the midwife and patient. Therefore, an unlicensed midwife can agree to attend breeches, VBACs, multiple gestations, or whatever - and can charge for services rendered. Most have transfer agreements with at least one doctor or hospital if needed. But no 3rd party payers (insurance, Oregon Health Plan) will reimburse for this care. Care with these midwives is strictly caveat emptor. Most are highly qualified, and are more than willing to provide references, educational background, and a written informed consent agreement to patients, but not all.
There are also licensed midwives in Oregon.
Certified Nurse-Midwives are licensed as nurse-practitioners, and must have a master's degree. Their scope of practice is determined through the Board of Nursing. The fee for this license is a few hundred dollars, not including costs for mandatory continuing education. CNMs practice can be at home, in birth centers, or in hospitals. Most CNMs have pretty strict boundaries on whom they will attend, and stratify patients in to one of three levels of care - 1) midwifery only, 2) midwifery with physician consult or 3) refer all care to physician. Most CNMs do not attend breeches or multiple gestations routinely.
Licensed Midwives must go through a credentialling process including verification of experience and a written exam. With licensing, the midwife is allowed to carry and use certain medications and controlled substances (pitocin, methergine, oxygen) under protocols. The licensing agreement also excludes certain classifications of pregnancy from care by this group. (I don't remember the exact boundaries, but they are the kinds of moms that a CNM would also consult on or refer out). The licensed midwife will also have working relationships with physicians for conslutation and referral. In Oregon, licensed midwives were able to bill insurance and the Oregon Health Plan until the move into HMOs. Licensing fees for this class of midwife is in the thousand dollar range, as the Board is required by state law to be self sufficient.
Anyhow, my friend was on the Board for licensing of midwives, and was licensed among the first group after establishment of the law, but has let her licensure lapse. And she isn't the only one. Licensure was held out to them as a potential for being able to practice midwifery with a firmer foundation. Legal recognition, 3rd party reimbursement, legal access to life saving anti-hemorrhagic drugs, more articulated transfer of care for the small percentage of moms who need it - these all seemed to be pretty clear advantages. But the reality has been different. There was an increase in overhead cost, a loss of autonomy, and the 3rd party reimbursement never really happened as promised. And so my friend, and many like her, are back to where they were before licensure came in. For hemorrhage, she uses massage, compression and herbs, and transports if needed. Although she has the skills to start an IV, and the knowledge of how to use anti-hemorrhage drugs, the costs of the license to use them are too high, both to her and to the families she serves.

Midwifery Comments


I am trying to put together part 2 of my midwifery comments, but it is slow going. Part of it is that I don't want to overwhelm my audience, but there is so much that needs to be said! I have been studying this since I was 10 years old, and practicing for a long time too. It isn't really a 'sound-bite' type of topic, either. Your patience and prayers are appreciated.

I'm in a book!


On pages 77 - 79 of Ina May's Guide to Childbirth is a story of a birth I was at during my L&D nurse days. Let me also quote Ina May from page 307 of this book. "it is not possible to determine solely by licensure, certification, gender, profession, or outward appearance the philosophy of practice of any given practitioner. Not all midwives work within the midwifery model of care; not all doctors work entirely within the limits of the medical model of care. Women are not necessarily more sensitive than men...." And I will add that all providers work within systems that may have a negative or positive impact on the provider's ability to give the best care. Money, politics, and culture all get into the mix.
Anyhow, I stopped housework when the delivery of this book came from amazon.com. Time to get back to work.

The Joy of Natural Childbirth


I highly recommend The Joy of Natural Childbirth: Fifth Edition of Natural Childbirth and the Christian Family, even though it can be hard to find. Actually, any edition from the first on through the fifth is valuable. I read it when I was pregnant with my first in 1974, and it was one of the books that helped me to find my vocation as a midwife. The author, Helen Wessel, is now deceased, but I had the opportunity to meet her in 1983 at the ICEA conference in San Diego California. In addition to her deep Biblically based belief in God's creation in childbirth, she also was a strong proponent of NFP. She influenced the Sears' (well-known Pediatrician/RN married couple) and many others in her long life. Her work is being carried on through Apple Tree Family Ministries. I would be delighted if I could find a Catholic family group that could carry out some of this same ministry.

HMS Debate


A reader alerted me to a debate going on over at the Exceptional Marriages (aka HMS) blog. It is kind of confusing to follow the thread if you haven't been a regular reader, but it has to do with a case where a midwife is about to go to jail for saving a woman's life by treating her with a drug that she obtained illegally. If you search the archives using the keyword 'midwife' you will find the debate. It starts with an article in National Review Online. Take a minute here and go read the article and the thread over at HMS.
Both Kevin Miller and Greg Popcak give reasoned defenses of their opposing positions. Duncan Anderson has a rather impassioned response to his experiences with hospital birth policies and procedures. All of these gentlemen have a lot of light to contribute to what is actually a quite complex situation encompassing politics, power,money, fear, and human life. None of them are midwives, and none of them are mothers. I don't know for sure, but I also doubt that any of them are lawyers.
It wasn't that long ago that midwifery was regulated by canon law, and midwives were seen as performing a valuable ministry in the service of life.
I am a midwife. I am a mother. I am not a lawyer, or a moral theologian, or a clinical psychologist. I have been involved with pregnant women and their families on a professional level for more than 20 years. I have studied the physiology, psychology, ethics, sociology, theology, anthropology and just about every other -ology of birth over the last 30 plus years. I have worked in women's homes, in birth centers, in hospitals ranging in size from 22 beds total to 18 thousand births a year (LA County/USC medical center Women's hospital).
As I posted earlier, in the early years of the 20th century, a concerted effort was made to completely eliminate the midwife. Part of the strategy was to turn nurses and midwives against each other, and it nearly succeeded. Even now, dominance games are being played over the bodies of pregnant women, as various providers of prenatal and birth care attempt to protect their own corner of 'the market' by bad mouthing the others. The behaviors of some care providers provides plenty of fuel. It may not matter whether the provider is the hospital labor nurse, a family physician, a traditional birth attendant, a perinatologist (specialist in medically difficult pregnancies), a professional midwife, an obstetrician/gynecologist (that's a weird marriage - medicine and surgery do not mesh well in the same body!), a certified nurse-midwife, or even a chiropractor or naturopath. (See my article What is a Midwife? for descriptions as well as some of my opinions). There will always be some who through pride or greed exceed their level of competence, or who are simply so attached to a certain ideology that they can not see any other paradigm.
There are unacknowledged issues in the Freida Miller case, as in so many other midwifery cases that have percolated through the courts since the 1960s. One is simply to define what constitutes the practice of midwifery. Is it a branch of medicine, a branch of nursing, or a discipline in its own right? If (as I and many others believe) midwifery is a separate discipline with borders and connections to both medicine and nursing, who should regulate midwifery (if indeed it should be regulated) in the public interest? What provisions should be made for the areas where midwifery intersects with medicine, nursing, and surgery?
Midwifery is a body of knowledge that does not require a nursing diploma or a science degree to be accessable. It requires both didactic (book or classroom) learning and experiential (apprenticeship, internship, preceptorship) learning. For a nurse to become a midwife often involves unlearning as much it does learning. It actually would make more sense to require a nursing credential and experience for medical school than it does to require nursing for midwifery. There is much more common ground (especially pathology) between nursing and medicine than there is between nursing and midwifery. The normal physiology of a pregnant, birthing, post-partum and lactating woman changes week by week, and is so different from that of a man or a non-reproducing woman that basics like what are normal vital signs and normal common lab values must be relearned. Just one example - at 28 weeks of pregnancy, if the hemoglobin and hematocrit do NOT drop to levels that in the non-pregnant would be considered fairly severe anemia, there is something wrong with the pregnancy.
In 90 to 95% of cases, pregnancy, labor, and birth can be handled, and handled well, without needing prescription drugs. Good nutrition, a healthy lifestyle, marital chastity, and watchful waiting are all key factors. Hemorrhage, one of the 'big three' killers of women through the ages, can often be prevented with good midwifery skills (especially in the delivery of the placenta), but is one of the conditions for which most midwives prefer to have medication available. A real issue is that the same drugs that stop hemorrhage after the baby is out can also induce labor or abortion. Therefore, there are certain precautions needed when giving them. That is why they are prescription items. There are also non-drug ways that can help slow or sometimes stop excessive bleeding, and many midwives who do not have prescription privileges use only non-drug methods. (BTW - there are a few states where even nurse-midwives cannot prescribe medications). However, most midwives do carry and have been trained in the use of these drugs for hemorrhage. And many will continue to carry them, even knowing it is a violation of the state law, in the unlikely event of a situation like the one Freida Miller found herself in. They get these drugs in various ways. Some get them from physicians. Some get them from abortion clinics. Some go to Mexico where they can be purchased by anyone in a pharmacy. Some steal them. A few tell the women to get a prescription from their own family doctor, if possible.
Due to the politics of home birth, many physicians risk their own career and livelihood by providing any help to a home birth midwife, regardless of the midwife's credentials, licensing status, or other qualifications. A midwife who refuses (as Freida did) to divulge the source of her life-saving if illegal drugs, is probably protecting not only that physician but any others who may see it as their duty to assist those who attend women birthing at home.
In some ways, this is similar to the journalism jailings for refusing to name sources. Many see these actions, and the many other situations that have caused miwives to end up in jail, as a form of legitimate civil disobedience, similar to blocking abortion clinics, violating Jim Crow laws, smuggling slaves north before emancipation, and so on. Others see it as just being stupid or criminal.
It is not unusual for outside observers to be puzzled by the seeming intransigence of midwife defendants. Where licensing of some kind is available, they think, why don't these people just jump through the hoops to get the license? The answer to that is another whole story, one I will try to get to when I can.

Cesarean sections


Two Sleepy Mommies post links to a discussion on a topic near and dear to my heart - the move towards elective (not medically indicated) Cesarean sections. I have a lot to say on this, but I am sleepy and have to work tomorrow. I will make one comment right now, though.
In the 1970s and afterwards, the country of Brazil had the world's highest Cesarean rate. The overall rate was estimated to be 75% of all births. Since normal birth was still the usual method for the poor and rural folks, this meant that the cesarean rate among the well to do and city dwellers was closer to 100%. In my current practice I see lots of women from Brazil. The majority of those who have had babies, whether in the last few years or 30 years ago, had cesareans. Many of the older women had cesareans because they could have their tubes tied or a hysterectomy afterwards. It was very much part of a culture that denied the procreative part of femininity while accentuating the sexual pleasure (for their husbands?) aspect. Comments I heard were along the lines of "I wanted to stay tight for my husband" and "It was easier to set a day and get it over with". What I find really interesting is the daughters of these women, often brought to the USA as children or teens, are rebelling against their mothers and culture by demanding vaginal births.



Government Support of Natural Family Planning
"It [contraceptive] doesn't work. [Artificial birth control] is more complicated than just giving condoms," said Health Secretary Manuel Dayrit in a media forum at Clark Field in Pampanga on Thursday.
I knew many Filipina nurses in my days in Los Angeles. I wish I could ask some of them about this news from their home country. I also wonder what kind of response this program will get from the Muslim minority and from the Evangelical Christian groups that are so busy in the Philippine Islands.
Link from The Accidental Choir Director.

Midwifery again


My profession is one of the first mentioned in the Bible. Exodus chapter one has lots to say about midwives, and our responsibility to God and to the families we serve taking priority over the laws of Pharoah. It also mentions that God rewarded the midwives who obeyed him. There are very many midwives who have a strong Christian ethos that is incorporated into the way that they practice. However, I will say that it is very difficult to work within our current health care chaos (I refuse to call it a system) and maintain these values. I had a number of revelations while reading Scott Hahn's book A Father Who Keeps His Promises: God's Covenant Love in Scripture. Ideally, the midwife and the family she serves would see this relationship as more of a sacred covenant than a secular contract. I think that many come into midwifery with this level of idealism and committment. It often does not survive intact. Among the factors that may cause damage are societal and cultural expectations as to who has ultimate responsibility. There is a culture of fear. There is a lack of acceptance of 'unfortunate outcomes'. There is the tendency to assume that the birth attendant is ultimately at fault if there is any problem with the mother or baby.
Midwifery is at great risk in our current culture. There are financial pressures that make it difficult if not impossible for women and their families to choose to have a midwife attend them in birth, especially in some settings. In some areas, the only midwives available practice only at home, or in a birth center, or in a hospital. Midwifery should be avaiIable in all these settings. I long for the day when pro-choice no longer means pro-abortion but speaks to the right of a family to choose where and with whom to give birth. Because the midwives feared God, he made them to prosper. To me this means that I will not prosper, nor will my sister midwives, unless we first fear God. And this means that we must, MUST, obey the natural laws that God set forth. We must eschew support for immorality. We must speak the truth with love to those who seek our care. We must pray, and bless those who curse us, and praise God from whom all blessings flow.

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About this Archive

This page is a archive of entries in the Midwifery category from March 2003.

Midwifery: February 2003 is the previous archive.

Midwifery: April 2003 is the next archive.

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