Over-Intervention in Maternity Care is a Global Concern

The Wilson Center, the nation’s key non-partisan policy forum for tackling global issues through independent research and open dialogue to inform actionable ideas for the policy community, recently convened a panel of experts to discuss Too Much Too Soon: Addressing Over-Intervention in Maternity Care. The panel included Saraswathi Vedam, an associate professor and lead investigator at the University of British Columbia’s Birth Place Lab; Suellen Miller, Director, Safe Motherhood Program; and Myriam Vuckovic, Assistant Professor, International Health Department, Georgetown University.

 

From the Wilson Center website:

For years, the primary approach to improving global maternal health was additive – to increase capacity to address shortfalls in clinics, doctors, supplies, information, and skilled care. Today, however, some women are experiencing issues related to the opposite problem: too much.

So called “over-intervention,” such as the use of Caesarean sections, ultrasounds, and antibiotics when not needed, are costly for health systems and can be dangerous for women and newborns. In addition, it calls attention to whether women are being allowed to make decisions about their own health care under pressure.

“An indicator for poverty and for equity today is quality – the lack of quality,” said Anneka Knutsson, chief of sexual and reproductive health for United Nations Population Fund, at the Wilson Center on April 24. “It comes in the form of underuse, it comes in the form of overuse, but increasingly, the lack of quality is about over-intervention, of losing sight of what is ‘normal’ childbirth and supporting that physiological process.”

In parts of the world, “We have these huge numbers of women going into hospitals with three to a bed and overcrowded hospitals and terrible conditions, and we have not improved the outcomes,” says Dr. Vedam, who is also chair of the Home Birth Summit.  “Institutional birth has not been shown to be the answer,” she says. Instead, “it’s about skilled attendants and respectful care.”

You can access a recording of the entire two hour streamed event here.

A twenty minute podcast of Dr. Vedam’s presentation “Reducing Over-Intervention in Maternal Care Through More Autonomy” is available here.

 

PLEASE READ OUR FULL NEWSLETTER FOR ARTICLES ON NEW EQUITY RESOURCES AND RISK ASSESSMENT IN COMMUNITY SETTINGS

Chapter News

Chapter Goals and Priorities for 2017

The NACPM State Chapter Program continues to expand with each state honing in on its unique work and projects. We currently have 12 fully formed chapters in North Carolina, South Carolina, Pennsylvania, Ohio, Minnesota, Illinois, Maine, Wisconsin, Washington, Nevada, Florida, and Oklahoma. Several more states are well on their way, and even more have expressed an interest in forming. The most recent Chapter Collaboration Call was an opportunity for chapters to share their 2017 goals and priorities with one another and with NACPM leadership. Here are a few highlights:

 Meredith Christie, president of the North Carolina Chapter of NACPM, reported on their NC MERA collaboration with CPMs and CNMs in the state, which recently met and began plans to organize a NC Community Birth Summit modeled after the Home Birth Summit.  They hope to facilitate community conversations with various care providers and stakeholders at the summit.  They are also working on transport guidelines and hoping to coordinate a “Smooth Transitions” project modeled after WA state.

 Christy Santoro, president of the Pennsylvania Chapter of NACPM, shared about their plans to host a forum around questions of equity, race, and access to care in midwifery.  This state level exploration in PA is deeply resonant with NACPM’s commitment to addressing these critical issues nationally.  NACPM is excited to see the PA Chapter design this forum, and will seek to empower and equip other chapters to bring this important work forward in their states.

 Korina Pubanz, founding board member of the Wisconsin Chapter of NACPM, reflected on the value of the Chapter Collaboration Calls saying, “midwifery practice, legislation, and educational opportunities vary from state to state- it is so interesting to hear how the challenges are being met and great work is getting done. When I have participated in conversations or just listened to the work that is being put forward I can’t help but be motivated and also deeply appreciative for the work that has already been done in our state of WI.”

 State Home Visits

Mary Lawlor has made several more “home visits” to state chapters and chapters in formation in MN, WA, and CO.  Mary makes these visits both in response to crisis, like in Oklahoma last quarter, and more often simply to learn about the unique experience in each state while also sharing about the important work being done on the national level.  These visits are vital to maintaining open lines of communication between NACPM and the midwives we serve.  Kate Hogan from the MN Chapter of NACPM reported that “the MN NACPM chapter had a wonderful visit from Mary Lawlor this March. We so enjoyed getting to hear what is happening in the national midwifery community, and our local community was able to learn about and get many questions answered regarding US MERA. Our chapter is excited to be a part of working towards the NACPM strategic priorities.”

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NACPM Chapter Team left to right: Kirsten Archibald (Office Manager), Susan Smartt Cook (Chapter Program Manager), Mary Lawlor (Executive Director), Jo Anne Myers-Ciecko (Consultant), Joanna Roche (Program Manager)

Would you like to nominate an extraordinary leader in your state?  Let us know!  We would love to recognize them in our State Chapter newsletter.

Contact Susan at chapters@nacpm.org. 

If you are a chapter member or leader of a chapter in formation, please save the date for our next Chapter Collaboration Call on Tuesday June 6th from 1:30-3:00 ET.  We will be discussing NACPM’s new comprehensive set of NACPM briefing papers and recommendations, to be released in early June, which describe NACPM’s vision and the emerging landscape and future directions for CPMs.  Watch your email for more information.

READ ABOUT AN UPCOMING WEBINAR IN THIS WEEK’S NEWSLETTER


International Day of the Midwife, Friday, May 5

“Midwives, Mothers and Families: Partners for Life!” is the theme for International Day of the Midwife this Friday, May 5th. The International Confederation of Midwives (ICM) invites and encourages midwives to share your views, photos, stories using the phrase “I believe in partnership” on all ICM information platforms as a celebration of the wonderful work that midwives do around the globe. When you share your stories and photos, make sure you include #IDM2017. Click HERE to watch a video example of Nester T. Moyo, ICM’s Senior Midwifery Advisor, as she shares her views on partnership between midwives, mothers and families.

A message from Sally Pairman, ICM Chief Executive:
“Midwives everywhere understand that by working in partnership with women and their families they can support them to make better decisions about what they need to have a safe and fulfilling birth. It is evident that midwives deliver more than babies, in many instances they provide comprehensive sexual and reproductive health services and play a critical role in promoting health issues in their communities. As members of their communities, midwives are familiar with community issues, cultures and challenges. Working in partnership with women allows midwives and women to get to know each other and build trust and respect. Midwives can then provide individualized care that meets each woman’s needs, is culturally safe, includes the woman’s family and is therefore more likely to have a lasting impact.

Access to a skilled midwife can help reduce and prevent deaths of more than 287,000 women who die while giving birth, those who are left morbidities and 2.7 million newborns who die within the first 28 days of life because they have no mothers. That is why we need to take this partnership between midwives and mothers to a political level. If midwives and women and their families raise their voices together to advocate for changes to midwifery and maternity services they can combine their political power to make more impact and bring about changes so that services meet the needs of women and midwives.

The ICM has prepared a fabulous resource pack with all kind of ideas and tips for celebrating International Day of the Midwife. You’ll find useful advice for planning a special event, tips for issuing a press release, and great examples for posting on social media like Twitter and Facebook.   You can also download logos and posters.

We hope you’ll find a way to celebrate and share your stories on International Day of the Midwife.  But if you do nothing else this Friday, take a few minutes to breathe deeply and let yourself really feel what it’s like to be part of the global community of midwives numbering in the hundreds of thousands.   Hold close to your heart the midwives working in South Sudan where the maternal mortality rate is 2,000 per 100,000 live births.

Imagine the millions who will benefit because Bangladesh, Afghanistan and Kyrgzstan are implementing a Midwifery Services Framework (MSF) that supports the development and strengthening of midwifery services, with a focus on a quality midwifery workforce.

Celebrate the midwives right here in our country, midwives like yourself, who persevere despite the many obstacles and provide community-based care that transforms lives!

 

Virtual International Day of the Midwife (VIDM) 2017

The Virtual International Day of the Midwife (VIDM) is an annual free 24-hour online international conference celebrating midwifery and birth-related matters on IDM.    This is the 9th annual conference and features speakers from around the world, including Scotland, Iran, Ethiopia, Germany, Indonesia and more!  Topics range from working with refugees to integrative and complementary health care to post-traumatic stress among midwives.  ICM Chief Executive Sally Pairman will be leading the final session.  The VIDM conference spans May 4 and 5 depending on your time zone and the program can be accessed HERE.

 

ICM Triennial Congress to Convene in Toronto in June

More than 4,000 midwives are expected gather in Toronto, Canada from June 18th to 22nd for the 31st ICM Triennial Congress.  It’s not too late to register for this incredible opportunity to be part of the learning and action around the theme “Midwives: Making a Difference in the World.”  The last congress in North America was held more than 20 years ago in Vancouver, British Columbia.  The next Congress will be held in Bali in 2020.

For those lucky enough to be able to attend the Congress, be sure to arrive early for the March for More Midwives on Saturday 17 June when thousands of midwives will take to the streets as part of a spectacular parade through the city. ‘The world needs more midwives now’ is a theme that resonates in many parts of the profession where there are insufficient midwives or inadequate funding for midwife education and more trained midwives. The march will draw attention to the role of midwives in reducing maternal and baby ill health or mortality.

International Council Meeting

ICM is governed by the international Council which meets in full every three years for four days immediately before the Congress.   As a member association, NACPM will send two voting delegates to the Council meeting.  Delegates debate and discuss policy and update core documents including Position Statements, Guidelines, and Midwifery Standards. They provide strategic direction for ICM. They review financial statements and reports. The Board for the next triennium is appointed. The Council also hears presentations from three shortlisted Midwives Associations (countries) and votes on the Congress country for 6 years hence.

READ THIS WEEK’S NEWSLETTER HERE

Come Look Through the Window: NACPM Leadership Team Meeting

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When you gather passionate people around a shared purpose it becomes a testament to one of the core principles of the model of distributed leadership: together we are all smarter than any one of us alone. Although the full NACPM Leadership Team–Board, staff, and consultants–meet virtually via Zoom every month and our project teams are in contact on an even more regular basis, there’s a particular synergy that happens in our semi-annual in-face meetings. As Frederic Laloux writes in Reinventing Organizations, “When the individual and organizational purpose enter into resonance and reinforce each other, extraordinary things can happen…we often feel overcome with grace. It feels like we have grown wings. Working from our strengths, everything feels effortless and we feel productive like rarely before.”

Here are some of the highlights of our Spring 2017 Leadership Team meeting:

  • We spent time revising the NACPM Purpose Statement to encompass and reflect our broader, more inclusive goals, and our current working draft is: “NACPM’s purpose is to do our part to ensure a healthy start for all childbearing people and their babies. NACPM supports CPMs in their practice of the art and science of community-based midwifery, influences health policy to widen access to compassionate, physiologic care, and partners with stakeholders to eliminate birth outcome disparities for families in the United States.”

  • Team leads for each of our projects and focus areas reported on the work their teams have been doing and we celebrated progress on several fronts: a dramatic increase in the number of members; planning for the 2018 CPM Symposium; status of our fundraising efforts; the launch of the NACPM legislative toolkit and response from the states; the gathering of information and input from MEAC-accredited programs necessary to advance our efforts to develop a scholarship and mentorship program for student midwives of color.

  • We also reviewed the overwhelmingly positive feedback we’ve been receiving about our professional development webinars and noted that participation is robust, with over 600 participants in 13 webinars since September 2016. We are proud that the webinars are providing a valuable resource to our professional community as evidenced by the number of CEUs that have been granted over the past eight months, including a number that qualify for the Midwifery Bridge Certificate. We discussed how to continue to ensure that the recorded webinars remain archived and easily available on the NACPM website.

  • We celebrated the launch of several new NACPM state chapters. We discussed how best to support these chapters, how to fully engage their members, how to improve connectivity and continue to build communication and collaboration between the chapters through the quarterly calls, and how to continue to expand this dynamic network.

  • We participated in a lively team activity/discussion, based on the StrengthsFinder assessment tool and facilitated by Dr. Brian Perkins, to identify our core values and our individual and collective strengths. We are committed to developing our leadership skills and anticipate that this StrengthsFinder exercise will add significant value to both our individual work and our work as a team going forward.

  • Lisa Kane Low, ACNM President, joined us for an hour and 1/2 and we shared information about priorities, current initiatives, and some of the challenges faced by both of our organizations.

  • We hosted a dinner and conversation with leaders from the D.C. birth community and learned about the inspiring work they’re doing to provide access to high-quality care in historically underserved communities.

  • We laid the foundation for an exciting new partnership in our work to build a more representative midwifery workforce and promote equity in maternity care outcomes–look for details about this emerging partnership in upcoming newsletters.

  • Our communication team unveiled a comprehensive set of NACPM briefing papers and recommendations, to be released in May 2017, which describe NACPM’s vision and the emerging landscape and future directions for CPMs. Watch for the release and distribution of these papers over the next few weeks.

  • We welcomed Camille Sealy, M.Ed, MPH to the NACPM Leadership Team! Camille joined NACPM in the winter of 2017 as our second Public Member of the Board. She currently serves as a Senior Advisor in the Office of Legislation at the Health Resources and Services Administration (HRSA) where she provides strategic direction and leads legislative efforts for the agency around various issues including health workforce, maternal and child health, and primary care. Previously Camille served as a health Legislative Aide to congressional members in both chambers. During her time on Capitol Hill, she drafted provisions within the health reform law pertaining to maternal and child health, prevention and wellness and disparities. Camille presented at the 2012 CPM Symposium with a talk entitled: Maternal Mortality in the U.S.: Taking Action to Eliminate Disparities in Maternal Health Outcomes. In her free time, Camille runs, gardens, and volunteers at the Smithsonian National Museum of African American History & Culture. Prior to our D.C. meeting, Camille made it possible for several members of the NACPM leadership team to visit the museum. We’re so grateful for that opportunity and are thrilled that Camille has joined us!

  • In our ongoing effort to become a truly multicultural, anti-racist organization, we challenged ourselves to sit in discomfort, to stay in “the confusion room,” knowing that new and important insights and authentic ways of engaging will emerge from the work that happens in that somewhat chaotic and not always comfortable place. With the help of our skilled and compassionate facilitators, Shirley MacAlpine and Cari Caldwell, we explored the difference between comfort and safety, between intent and impact. We confronted the impact of our words and our actions and held ourselves and one another accountable. We also recognized the importance of apology and doing the necessary work of repair.

  • Throughout our time together, we deepened our understanding and practice of distributed leadership model and honed our skills as members of an emerging Teal organization. To learn more about the core elements of Teal organizations (self-management, wholeness, and evolutionary purpose), check out the book Reinventing Organizations by Frederic Laloux; or go to the website

NACPM strives to continually engage CPMs and stakeholders in envisioning and implementing the role that CPMs can and must play in improving the health, and even saving lives, of childbearing people and their babies in our country. As described above, we do this through our chapters, our professional development webinars, our ‘home visits’ with state midwifery leaders, our outreach to other professional organizations, and we look forward to the opportunity to plan together for the profession with our members and stakeholders at the 2018 CPM Symposium. NACPM strives be a resource for up-do-date information on practice, regulation and health policy impacting midwifery. Watch for information coming soon about the 2018 CPM Symposium and emerging partnerships. Visit the NACPM webpage regularly, sign up for newsletters and other announcements, follow NACPM on Facebook, participate in free webinars, and reach out to NACPM staff for assistance. Join NACPM and your NACPM State Chapter as a CPM, student, or associate member. We look forward to our continued work with you throughout 2017 and beyond.

With all best wishes,

Tanya Khemet, CPM, MPH and Audrey Levine, CPM (Ret)

Co-Presidents, NACPM

Domestic Violence and the Midwife

As midwives we need to be able to identify indicators of domestic violence in all its manifestations. Midwives are uniquely positioned to be able to pick up cues ­ we typically spend more time with clients at each prenatal visit, our focus is on holistic health including the psychosocial aspects of family wellbeing, we provide continuity of care, and conduct home visits. The nature of the midwife­-client relationship builds trust and promotes disclosure. It is not unusual for a client to say, “I’ve never told anyone this before…” and share some intimate information that helps us better understand and safeguard the health of the mother, baby and family.

READ MORE IN THIS WEEK’S NEWSLETTER

State Legislation Update and Harking Amendment Victory in Oregon

State Legislation Update

Momentum continues to build as more states include the US  MERA  agreements and principles in bills to license Certified Professional Midwives, helping to overcome opposition to the regulation of CPMs that has stymied efforts, often for years and at times even decades.   In addition to legislation to license CPMs, midwives and consumer advocates are stepping up in other states to address threats, and to rise to challenges as well as to emerging opportunities.  As we share our experiences with legislation and regulation, state to state, we build our common body of expertise to promote and protect the practice of certified professional midwifery.  We are pleased to provide you with these updates and look forward to keeping you abreast of further developments in these and other states in the months to come.

Illinois

The Illinois Council of CPMs – a Chapter of NACPM – and the Illinois Friends of Midwives have introduced the Home Birth Safety Act in both the House of Representatives (HB 677) and the Senate (SB 1754), the same legislation that these groups collaborated on last year with ACOG.  With over 1000 babies being born out-of-hospital a year in the state, Illinois ACOG and the midwives believe passage of this bill is a matter of safety for mothers and babies choosing home birth.  Aligned with the US MERA agreements, the bill passed out of the Senate Committee of License Activity and Pensions on a 9-2 vote this session, with a promise by the midwives to committee members to further engage with the Illinois State Medical Society who have opposed the bill.  A meeting of the parties took place in March, with the Illinois Medical Society agreeing to take the information the midwives provided to them on CPMs and MEAC-accredited education back to their board for discussion.  The primary Senate sponsor of SB 1754 has committed to keeping the bill alive and to bringing this legislation to the floor for a vote of that chamber, as soon as next week.

Kentucky

Two identical bills to license CPMs in Kentucky have been introduced, one in the House (HB 148) and one in the Senate (SB 105).  HB 148 was heard in the House Committee on Licensing and Occupation, but received no votes this session.  Although the bill last year had more hearings and got further in the legislative process, more progress was made in activating the grassroots and building strength for this effort this year than last.  CPMs held seven regional meetings around the state this year, effectively engaging people from every corner of the state.  The CPMs in Kentucky are rightly proud of this outreach, which took much hard work and organizing, that allowed many more voices to be heard and engaged in the process.  Another victory this year was that the midwives were able to effectively stop an oppositional amendment to the bill sponsored by a house member with significant political clout, demonstrating the growing strength of the midwives and the grassroots and the support that is building in the legislature for this effort.  Advocates for this US MERA-aligned legislation are busy now preparing for the interim hearing period that begins in June.

Alabama

There are currently three bills in play in Alabama.  Advocates have brought forward HB 316 to license CPMs, a bill that aligns with US MERA agreements, and HB 315 that would exempt a midwife holding a current certification from NARM from the crime of practicing midwifery without a license – sometimes referred to as a decriminalization bill, a ‘back-up’ in the case the licensing bill does not pass.  A third bill, proposing to regulate the practice of ‘lay midwifery’ brought forward by the Medical Association of the State of Alabama (MASA), would effectively outlaw all direct-entry midwives except Certified Midwives, and does not have the backing of advocates for CPMs.  After years of rejection of any bills to license CPMs, HB 315 recently passed through the Judiciary Committee and HB 316 passed through the Committee on Boards, Agencies and Commissions; both bills are headed now to the floor in the House of Representatives.  Although there may still be much work ahead to secure passage of these bills, advocates are encouraged by the support they have found in these committees.

Oklahoma

Early this year, Oklahoma CPMs were unexpectedly challenged by the introduction of hostile legislation that would have effectively eliminated their ability to practice in the state.  By organizing quickly, engaging midwives and consumers and raising funds to hire an effective lobbying firm, they were able to push back this threat.  The newly-formed Oklahoma Chapter of NACPM was chosen by the CPMs in the state to act as the joint legislative arm for the two long-established state midwife associations, with the presidents of each organization serving on the board of the chapter, effectively bridging midwives around the state.

In February, NACPM Executive Director Mary Lawlor, attended the official launch meeting for the Chapter.  Midwives came from all over the state to share their concerns and challenges about regulation for midwives, and to learn together about the national picture that is emerging for certified professional midwifery.  They discussed the US MERA agreements and Principles for Model U.S. Midwifery Regulation and Legislation, and how alignment with these tools in other states is successfully building momentum.  The Chapter board then participated in a work session with Mary, using the NACPM Regulatory Assessment Tool from the NACPM Legislative and Advocacy Took Kit  to explore how the US MERA agreements and principles might be applied in Oklahoma to build a strategy for protecting autonomous practice in the state.

Florida

On March 29, the Midwives Association of Florida (MAF), consumers, and the Florida Chapter of NACPM celebrated an impressive turnout for Capitol Day in Tallahassee when many constituents met with their legislators in support of Licensed Midwives.  Physicians are seeking to require mandatory reporting of adverse incidents for Florida licensed midwives, to include reporting of maternal and fetal deaths, severe maternal hemorrhage, and transfers of mothers and infants to intensive care units.  The midwives agree with these requirements.  With the support of their lobbyists they are in dialogue with Florida ACOG about this legislation, which may involve opening up their midwifery practice act, a potential turn of events that is causing the midwives to strengthen their organizations and to rally support from around the state to ensure autonomous practice.

On another note, congratulations are in order!  The midwives in Florida are celebrating a long-sought victory:  as a result of 20 years of advocacy, new rules now provide for licensed midwives to do their own risk screening for new clients coming into birth center care, reversing a long-standing requirement that birth center clients have their initial exam and risk assessment with an MD or a CNM.

Washington State

With a more than 30-year history of policy and advocacy work, the Midwives Association of Washington State (MAWS), has lobbied this year for two budget provisos:  one to maintain the 8-year-old cap on the licensing fee for midwives, and the other to nearly triple the facility fee for birth centers paid by Medicaid.  Maintaining the cap on the annual licensing fee, which would otherwise now be triple the current rate of $525, has contributed to a 40% increase in the number of midwives in the state over these last 8 years, now nearly 170.  The increased birth center Medicaid reimbursement would not only benefit people having babies in Washington State, but could support efforts to increase the low rates of birth center reimbursement throughout the country, much as the 2007 Department of Health Cost-Benefit Study has helped make the case for Medicaid reimbursement for community birth in other states and to the federal government.

 

An Oregon Victory for the Harkin Amendment

Just last week NACPM was informed that an insurer, PacificSource in Oregon, has cited the 2015 guidance issued to the states by the U.S. Department of Health and Human Services (HHS) on Section 2706 of the Affordable Care Act (ACA) – commonly known as the Harkin Amendment – as the factor that has led it to finally issue reimbursement for direct entry midwife services provided to an Oregon resident in 2015.  Since the ACA passed in March 2010 until now, the implementation of the Harkin Amendment has been a discouraging story.

In agreeing to cover the costs of care for this consumer, the Oregon Insurance Division (OID) stated:  “…PacificSource has reviewed the Centers for Medicare and Medicaid Services (CMS) FAQ that provides additional clarification for provider non-discrimination requirements. The insurer has agreed that members who go to in-network Licensed Direct Entry Midwives can receive benefits under their policy. They also have agreed that members who seek out-of-network care by a Licensed Direct Entry Midwife would have their benefits paid at the out-of-network level the member policy permits (in a non-discriminatory manner).”

This victory is celebrated by the Integrative Health Policy Consortium and NACPM.  NACPM is an IHPC Partner for Health  and has held a board of director’s position for the last decade.  This new development in Oregon could portend well for reimbursement of midwife services for people having babies around the country.  Dogged persistence on the part of this Oregon consumer who had her baby at home with licensed midwives, along with support from the Oregon Midwifery Council and IHPC, has finally paid off in this unexpected but happy turn of events.  Of interest, the OID sent their email on the same day that the American Health Care Act (AHCA) was pulled from the floor of the U.S. House of Representatives, leaving the ACA as the law of the land.  Although it is likely that there will be no movement until fall of this year, there is reason to hope that the Oregon Insurance Division now will commit to fully implementing Section 2706 to address the current inconsistencies in coverage for professions in the state, and provide an example to other states on implementation of this important provision of the ACA.

The Integrative Health Policy Consortium was instrumental in working with Senator Harkin and other legislators during the development of the ACA to include Section 2706 to ensure patient access to care.  This provision of the law, sometimes known as the non-discrimination clause, requires that insurers include and reimburse licensed healthcare providers in health insurance plans.  It states:

(1) A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.

(2) This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

Notwithstanding small pockets of progress, implementation of this provision has met roadblock after roadblock since its passage.  In 2013, IHPC launched a nation-wide initiative to ensure adequate implementation of Section 2706 called Cover My Care, a national grassroots program of information and patient engagement designed to create public advocacy for access to all healthcare providers who are licensed by states.  Cover My Care provides a website,  information and FAQs about the law, patient guides,a toolkit for consumers and forums for consumer sharing.

In the coming months, IHPC and NACPM will be closely tracking progress of Section 2706, and providing all possible support for the goal of full implementation of this provision around the country.

 

 READ THIS WEEK’S NEWSLETTER HERE

Diversity Matters: What Are Our Challenges?

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The midwifery workforce in the United States is not representative of the racial and ethnic diversity of the childbearing population.

“Despite a long history of midwifery in the black community, black women currently represent less than 2% of the nation’s reported 15,000 midwives. Relatedly, black women and infants experience the worst birth outcomes of any racial-ethnic cohort in the United States.” Keisha Goode, PhD

The first two webinars in our “Equity, Race and Access to Midwifery” series focused our attention on the tragic disparities in maternal and infant outcomes, particularly among black families, the underlying physiologic effects of racism, and steps we can take to reduce disparities. This week Keisha Goode, PhD, and Nancy Anderson, MD, MPH, will discuss the barriers to attaining a representative midwifery profession and the positive impact that a truly representative midwifery workforce could have on health inequities. They report on their landmark research, designed to reveal the experiences of contemporary black midwives and students in midwifery education programs, practice settings, and professional associations. Their important findings and recommendations are a call to action for all midwives.

Keisha’s research is the first study to systematically investigate the experiences and perceptions of contemporary black midwives. Her dissertation, “Birthing, Blackness, and the Body: Black Midwives and Experiential Continuities of Institutional Racism” was completed in 2014 and includes a comprehensive examination of the history of midwifery, particularly among women of color and immigrants, and the long-lasting effects of racism, both as midwifery is generally perceived in the U.S. and within the profession as it has developed in recent decades. Keisha’s qualitative study, included both CPMs and CNMs, and was conducted via in-depth, semi-structured interviews that addressed these questions:

  • How do contemporary black midwives interpret the increasing medicalization and credentialism of midwifery and its impact on their work?

  • How do contemporary black midwives interpret the relatively high black maternal and infant mortality rate in the United States?

  • How do contemporary black midwives interpret the relatively low percentage of black midwives and black women’s underutilization of midwifery services in the United States?

  • How do black midwives perceive and experience national midwifery professional organizations?

  • How do contemporary black midwives understand their role, its possibilities and challenges, in addressing issues of cost, quality and access in the current health care crisis?

  • What are the differences in black midwives’ experiences and perceptions by age cohort, years of experience and type of midwife, i.e. CNM, CM or CPM?

Keisha’s findings have profound implications for midwifery educators and association leaders, for preceptors and midwifery practices, and for those who advocate expansion of the profession.

“To the larger midwifery community, listen to your midwives of color. The future of midwifery and positively impacting birth and birthing options for all women in this country depends on it.” Keisha Goode, PhD

The second speaker in this webinar, Nancy Anderson will share her research project/needs assessment that aimed to understand the barriers that women of color experience with respect to the midwifery profession. Sponsored by NACPM, the objectives of her study were:

  • Understand the role of unmet financial need as a barrier to women of color who wish to enter the midwifery profession

  • Determine the ideal scholarship structure for financial aid to women of color who enter midwifery education

  • Learn more about other barriers to successful midwifery education and practice for women of color.

A few highlights from Nancy’s findings:
The study identified several areas of resiliency and strength that were important to the success of women of color entering midwifery. These included previous work experience and expertise; community support and engagement; and sheer determination. Nancy also found that, while a variety of learning options could meet individual learning styles and personal needs best, the plethora of educational possibilities, each with differing financial implications and a variety of regulatory consequences, also highlights the importance of an organized outreach and information program for potentially interested women of color.

The importance of adequate financial resources for education is difficult to overemphasize, particularly in a population of potential midwives who may be more likely to be lower income at the onset of their midwifery education. One particular complexity is that midwifery education requires tuition, room/board and books, just as other higher education, but midwifery education also requires financial resources for travel to preceptor sites, steady supplies of gasoline and reliable transportation for births, and possible payment for the preceptors. Participants universally described a number of daunting financial challenges both at entry and during the course of their midwifery education.

By definition, someone who is an ethnic minority differs in a culturally prescribed way from most of her classmates. In the best of circumstances, these differences can be daunting. In addition to coping with cultural dissonance, women of color enter any midwifery educational pathway as experienced survivors of racism from childhood, previous education, and/or their employment experiences. Previous educational exposure may have occurred within institutions that were systematically deprived of adequate resources. Students of color carry this reality on their shoulders when they begin their midwifery education. Given the load that they carry, these students need systematic support from educational institutions.

Cultural dissonance, isolation, and racism can reach a zenith during clinical preceptor rotations when students may have to travel, dislocating to isolated locations with few people of color. Given the threats to the academic survival, both in classroom settings and during preceptorships, support in the form of mentorship becomes a key resource. It is the emotional equivalent of a life raft for midwifery students of color in midwifery.

Given the multidimensional needs described, it is recommended that financial and other support needs be integrated into a “package deal” that includes elements of social support, peer support and mentoring.

In her webinar presentation, Nancy will describe her specific recommendations and how they might be acted upon by midwifery education programs, educators, preceptors, and those who could mentor midwives of color.

Two other factors, occasionally forgotten in our concern for inequity, should also be important catalysts for targeted workforce development. First, the US overall is changing in ethnic distribution. As of 2012 there are already almost equal numbers of white and ethnic minority children in kindergarten. It is anticipated that by 2050 white Americans will be an ethnic minority in the United States. A health workforce that does not adequately represent the population it serves will never be able to anticipate or respond to their needs.

“The bottom line is that midwifery will need a more representative (as opposed to diverse) professional workforce to survive. While there’s good evidence that the model of care associated with midwifery can make a difference in the lives of women and babies, midwifery is a client demand-driven profession….no one has to choose a midwife and there’s no reason that they should unless they see themselves reflected in the profession.” Nancy Anderson, MD, MPH

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The NACPM Legislative and Advocacy Toolkit is Growing!

With feedback from our state chapter leaders and others, we are adding a new tool “How to Work Successfully with a Lobbyist” and several reference documents regarding the integration of midwives and midwifery care in the maternity care system.

Most states report that working with a professional lobbyist is one of several critical factors in their legislative success. Unfortunately, we’ve heard too many stories of groups that didn’t engage the best person for their purpose or didn’t really know how to work effectively with their lobbyist — wasting precious time, money, and even political support. NACPM’s new tool describes the criteria for selecting a lobbyist; clarifying goals and exercising appropriate control over the legislative efforts and strategy; clearly defining expectations, including costs; and regularly evaluating the association-lobbyist partnership.

Reference documents now available include the “Best Practice Guidelines: Transfer from Planned Home Birth to Hospital” and other guidelines or projects developed by perinatal collaboratives and various midwifery associations.

Our members have also requested that NACPM provide a statement on scope of practice. Our Legislative and Policy team is reviewing our core documents, as well as descriptions provided by the North American Registry of Midwives and official statements by the International Confederation of Midwives and other professional associations to prepare an updated definition for CPMs. Look for this to be finalized and added to the toolkit next month.

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Passion and Perseverance in South Dakota and Washington State

Congratulations to South Dakota!  Governor Signs Bill to License CPMs 

On March 1st, to the great joy of families across South Dakota, the state House of Representatives passed SB136 to license and regulate Certified Professional Midwives by a vote of 52-16 – exactly 25 years to the day when a baby boy was born at home while his father was recovering from an accident in the hospital.  After the birth, the mother and baby visited the father in the hospital, hospital personnel heard of the home birth, sparking a decades-long quest by the SD Department of Health to shutter the practice of all non-nurse midwives in the state.

On March 10th, Governor Dennis Daugaard signed the bill into law which will go into effect on July 1, making South Dakota the 30th state to establish a path to licensure for CPMs and adding to the growing number of states benefitting from aligning their legislation with the US MERA agreements.  With the $20,000 needed to fund the midwife regulatory board already in hand, thanks to the generosity of SD families, and the development of legislative rules about to begin, it is expected that the first CPMs will be licensed in South Dakota within a year.

The first bill to license direct-entry midwives in South Dakota was introduced in 1994.  In 1995, after giving birth to her 4th child at home, Debbie Pease joined the SD Safe Childbirth Options – which later became South Dakota Birth Matters, a coalition of concerned families advocating for access to midwives.  Over the next 22 years Debbie held various board positions, including Chair and currently Secretary, and has been the lobbyist for the group since 2009.

This legislative success is a story of extraordinary dogged perseverance, with advocates introducing a total of 33 bills over 25 years to expand and protect birth options for South Dakota families – including 9 licensure bills and 22 others to keep women, babies, families and midwives on the legislature’s radar.  “The timing was good this year”, Debbie told NACPM.  A combination of decades of showing up every year to educate lawmakers, having several prime sponsors positioned on key committees of jurisdiction, a sense in the legislature that “these people deserve to make progress” after all their years of hard work, and aligning the bill with US MERA agreements to overcome contention about the education of CPMs, paid off.   “It was a many-year strategy to wear down the opposition”, Debbie said, “and it worked! Every relationship you make takes you one step closer to your goal.”

Congratulations to all families in South Dakota – you inspire us all!

 

Persistent Perseverence: MAWS Lobby Day Turns 30

Consumers, midwifery students, and midwives are often a presence in state capitols when urging action on a new state licensure bill or fighting attempts to restrict midwifery practice.  But Washington State may hold the record for convening advocates proactively every year for more than 30 years in a row.  The Midwives Association of Washington State (MAWS) hosts an annual Lobby Day to make sure that legislators know just how important midwives are to childbearing families and the value they bring to the maternity care system!

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To learn more and see examples of supporting documents, check out the MAWS 2017 Electronic Lobby Day Packet for Legislators  and the Information for Lobby Day Participants.    Also available on the MAWS website is their 45 minute Lobby Day Training Webinar  which prepares advocates with an overview of the legislative process, facts about the benefits of midwifery, coaching to create your own “elevator speech,” and the specifics of this year’s legislative priorities.

Priorities for families and midwives this year included asking legislators to maintain the cap on midwifery licensing fees and triple the Medicaid reimbursement rate for birth centers.  Because of the clear cost savings and health benefits that licensed midwifery confers to the State of Washington as evidenced by the 2007 DOH Cost-Benefit Study, MAWS has successfully lobbied for this cap for the past 8 years.  Last year, MAWS successfully lobbied for a budget proviso directing the Health Care Authority (HCA) to review its methodology for setting the Medicaid reimbursement rate for birth centers.  MAWS leadership then worked diligently with the HCA throughout 2016, compiling data that went into a report sent to the legislature by the HCA in October, recommending that the Medicaid reimbursement rate for birth centers be increased to $1,742.  Midwives believe that, if they are successful in getting this budget proviso passed, not only will birth centers in WA State become more viable, but midwives, birth centers, and consumers in other states will benefit, too.

In addition to the specifics regarding midwifery licensing fees and birth center reimbursement, MAWS also supported several other bills, including:

  • a bill requiring that employers make reasonable accommodations for pregnant workers and that hospitals be required to institute baby-friendly practices, such as skin-to-skin contact immediately after birth;

  • a bill to strengthen the Family and Medical Leave Act by including a mandate for paid leave;

  • a bill to ensure that both midwives and doulas could have access to the state’s jails and prisons to be able to provide education and support to pregnant and postpartum inmates.

 

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Informed Consent and Shared Decision Making

Join us for this week’s webinar on Informed Consent and Shared Decision Making. Here is an opportunity to refresh and sharpen your understanding of the professional, legal and ethical requirements that underpin your practice. The presentation will also address how midwives and clients can use decision aids and electronic health records to support and document the information sharing and decision ­making processes.

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Are You Finding the Best Available Research to Inform Your Practice?

It often seems overwhelming these days to keep up with all the research available online to support decision-making for you and your clients. If you’re wondering where to look, what sources to trust, and how to interpret and apply the best research, don’t miss the next NACPM webinar “Evidence-Informed Practice: Research Literacy & Shared Decision-Making.” Dr. Courtney Everson, PhD, will answer these questions and more on Thursday, February 16th from 2:00 to 3:30 pm ET.

The following information about evidence-informed practice or EIP is drawn from Dr. Everson’s excellent presentation at the 2016 MANA Conference with co-presenters Shannon Anton and April Kline.

Evidence-informed practice (EIP) is that sweet spot at the intersection of the best available research evidence, the midwife’s professional/clinical expertise, and the client’s values and individualized needs.

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Figure 1 Courtesy of C. Everson

While EIP is fundamental to the model of care provided by CPMs, implementing it consistently can be a challenge for midwives and clients who have trouble accessing or understanding research, or who fear that research ignores individual client needs or supplants clinical expertise. Fortunately, the EIP cycle (Figure 2) can help you integrate research effectively with many new learning resources available to address these challenges. Attend the webinar to learn more about each step of the cycle!

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Figure 2 Courtesy of C. Everson

EIP has received increasing attention in recent years from health policy-makers and leading health experts who believe that developing a common knowledge base and language for EIP is key to improving inter-professional collaboration and optimizing health outcomes. Health professional educators are seeking to strengthen professional competency in EIP through enhanced coursework and skills development based on a set of specific EIP competencies. Nationally, six meta-competencies have been outlined for integrated practice that all health professionals are urged to achieve. Meta-competency #5 for integrated practice focused on “Evidence-based healthcare and evidence-informed practice.” Supporting this work is a priority of the Center for Optimal Integration, a strategic initiative of the Academic Collaborative for Integrative Health (ACIH). CPMs are represented on the ACIH Board of Directors nationally by Dr. Everson, Association of Midwifery Educators, and Nichole Reding, Midwifery Education Accreditation Council.

Midwives who want to take a deeper dive into the labyrinth of evidence-informed practice (EIP)—and achieve meta-competency #5 on EIP—can enroll in the Principles of Evidence-Informed Practice, a full 2-credit MEAC-approved online course taught by Dr. Everson at the Midwives College of Utah.

Midwifery educators who want to learn more about incorporating EIP competencies into their programs can visit the EIP Resource Guide for Educators at the Center for Optimal Integration website. Educators may also be interested in attending the annual conference “Process of Integrating Evidence (PIE) for Complementary and Integrative Health Educators” which will be held July 13th-15t, 2017 in Bloomington, Minnesota.

 
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Midwifery Educators: There’s Help Available!

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The Association of Midwifery Educators is beginning their second decade of “connection and collaboration” with an amazing line-up of projects and continuing education offerings.  Support for preceptors has been a priority for AME from the beginning and they offer an excellent series of on-line courses focused on the challenges encountered by preceptors.  Now AME is launching an exciting new series that includes:

  • Meeting the needs of adult learners

  • How to apply theories and principles of adult learning to curriculum, program design, clinical and classroom learning and meet the needs of diverse learners.

  • Student assessment: You taught it but did they learn it

  • Assessment tools that are fair, objective, accurate, valid, reliable; constructing effective test questions; norm and criterion referencing; learning management systems and test banking.

  • Ethics and Social Justice in midwifery education

  • Creating a socially conscious educational environment, applying principles of social justice to midwifery care within the context of the US health care system, moving individuals and institutions toward a culture of inclusivity.

There is also a wealth of information on AME’s website, designed to help anyone who is creating a course, looking for clinical teaching aids, thinking about starting a school or preparing a program for accreditation.  The website is well-organized so that preceptors, academic faculty, administrators, and aspiring midwives can easily find content that fits their interests.   AME’s Facebook page is another way to stay in touch with the latest news and resources.

The Clinical Directors Collaborative is another service AME provides to support midwifery educators. Clinical Directors of all the MEAC accredited midwifery schools meet monthly for 1 to 1 ½ hours to discuss topics and issues of mutual interest, to network, troubleshoot problems and share resources.  The monthly calendar is listed on AME’s Clinical Directors Collaborative webpage.

A recording of AME’s 2016 annual meeting held in December is available on their blog.  This one-hour meeting included updates on AME’s various projects which, beyond their web-based resources and continuing education courses, include:

  • Expanding Access to Midwifery School Accreditation, a new collaboration with the Midwifery Education Accreditation Council, to create a peer-to-peer institutional mentoring

  • Participation in the Academic Collaborative for Integrated Health’s Project to Enhance Research Literacy with the aim of developing a Guide to Evidence Informed Practice for Educators

  • Hosting meetings of the Clinical Training Task Force

  • Sponsoring student presentations at the MANA conference

  • Developing the AME Board of Directors through recruitment and training on power and privilege in midwifery, anti-racism and equity work

NACPM appreciates the tremendously important work being done by AME.  We are also thankful for the support we’ve received from AME over the years – co-sponsoring the 2012 CPM Symposium and partnering with NACPM to present our webinars.  We encourage everyone involved in midwifery education to join AME today!

 

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