====================================================

From: "faith_gibson" <ronnie@...>
Date: Sat Jan 29, 2005  2:41 am
Subject: Up/down vote of all LMs // attorney review // 4 elements malprac defined

Forwarded from Renee Anker// CALM survey of LMS:
"As of Today we have 21 responses w/ 3 no's and 18 yes's
Hmmmmm I think we're a bit ahead."

Faith ^O^

1) That is a ratio of 6 to one in favot of supporting the regs.

2) News from a California attorney specializing in administrative law
who reviewed the regs and CCM S&G.

Got a return call this afternoon from an experienced,
midwife-friendly, midwife-savey lawyer who provided a very balanced
report on pros and cons of the proposed regulations and the
incorporation of the CCM document as a standard of care.

Bottom line -- the regulation & CCM S&G is the best of our current
options and in general, a good document and a good outcome for LMs.

His evaluation was based on four major realities from the perspective
of the LM (did not consider issues of consuer safety, access to
care,informed refusal,etc). Those topics were

a) the daily practice under the regulations (whether they were legally
burdensome, cumbersome, restrictive, etc),
b) the strictly legal issue from standpoint of a defending an LM in a
disciplinary action,
c) the reality of MBC politics and their naturally resistive nature in
regard to midiwfery
d) how S&G can help or hinder in event of litigation (see short but
excellent definition immediately below on 4 elements necessary for to
sue for monitary damages)

a) In regard to easy vs. cumbersome daily practice, the standards were
both mother and midwife friendly, with clear parameters and lots of
flexibility. a B+

b) In regard to disciplinary actions brought by MBC, the specific
guidelines and minimum prac Requirements defend the competence of the
LM's if they have been followed, including routine charting and
especially memorializing in writing any decline of routine procedures
by parents or extenuating circumstances, such as 4 feet of show,
phones down,unable to consult or transfer care as per guidelines, etc

However, if identified routine care was NOT provided, having S&G would
establish your ommisions as substandard. If this also included or
contributed to a bad outcome, it would form the basis of judging the
LM's care as negligent. So good to have guideliens if they are
followed, bad to have if don't pay any attentions to them. So in
regard to litigation, its yes & no or a "C" grade

c) MBC/mfrypolitics: While this is 3rd in the list, it is ultimately
the dominating concern. No wiggle room on this one -- if you're going
down for the third time and someone on shore throws you a rope, the
wise thing to do is to take it and worry later about whether (or not)
the color of the rope matches your outfit. This one is a A+

d) In regard to avoiding culpability in event of litigation, a simple
principle leads: the plaintiff must establish that you owed a
identifiable "duty to the patient" and that failure to perform that
duty directly caused or indirectly contributed to demonistrable harm
or expense. Simple -- No duty, no foul, no fault!

This means if your profession can figure out how to collect large
professional fees WITHOUT having any identified duties, then you owed
the client nothing and can't be sued. For example, Christian Scientist
practitioners pray -- they have no legally identiifed duties, no
responsibility for outcome, can't sue them for fetal distress.

So if we REALLY wanted to protect ourselves from litigation, we would
have no standards, published no guidelines, make no promises and
assume no responsibilities, etc. However, the family may as well ask a
neighbor to stop by instead of engaging the professional services of a
licensed midwife.

So the answer is generally good in every category.

warm regards, faith ^O^
========================================================================
3)
The Four Elements of Malpractice
By: Kevin Madden, J.D.


Medical malpractice is negligence committed by a professional
healthcare provider whose performance falls below the standard of care
practiced by those with similar training and experience, resulting in
harm to a patient.

A patient must prove four elements in order to prevail in a negligence
action:

1. A duty was owed to the patient by the health care provider;
2. The health care
provider breached that duty;
3. That breach of duty is the cause of
the patient's injuries;
4. Those injuries resulted in damages.
[The most important issue being "foreseeable damage".]

The following is a brief description of each of the four elements of
negligence. There are hundreds of cases in each jurisdiction in the
country interpreting the law on these elements as it applies to
different scenarios.

DUTY



The medical provider's duty arises from the physician-patient
relationship. Although the duty requires mutual consent, it is usually
entered into implicitly.
For example, giving a patient an office appointment may create a
relationship, or scheduling a procedure for a patient. A duty may also
arise from giving medical advice to an acquaintance at a social gathering.

The doctrine of vicarious liability may impose liability on a provider
for the wrong doing towards others. For example, hospital staff or
nurses under a physician's direction may perform negligent acts for
which the physician may be deemed liable.

BREACH


Breach of duty means that the medical treatment
provided fell below the standard of care. The standard of care is a
minimum standard to which health care providers must adhere to avoid
negligence
. The standard is specific
to each field of practice. For example, anesthesiologists determine
the standard of care for anesthesiologists, whereas cardiologists
determine the standard of care for cardiologists.

The standard is also somewhat specific to the practice setting, in
that a small rural hospital with minimal equipment may not be held to
the same standard of care as a large metropolitan or university hospital.

Expert opinion testimony is often necessary to prove a breach of duty.
The plaintiff's expert physician will come before the trier of fact
and establish what the expert believes to be the standard of care, and
how the conduct complained of deviated from that standard. A defense
expert will then have the opportunity to appear to counter that testimony.

An expert witness is not required to prove a breach when the doctrine
of "res ipsa loquiter" (the thing speaks for itself) applies.




The plaintiff must prove three things for the doctrine of "res ipsa
loquiter" to apply:

1. It must be common knowledge among laymen that the accident is the
sort that does not ordinarily occur in the absence of negligence;

2. The
injury-producing instrumentality or conduct must have been within the
control of the defendant.

3. There must be an absence of intervening factors
that may have altered the event.

CAUSATION


To achieve economic success in a lawsuit, the plaintiff
must prove that the breach of duty was a substantial factor in the
cause of the damages suffered. This is often the most difficult part
of a case to prove.

DAMAGES


Damages are the losses suffered by the litigant. In medical
malpractice cases, they are generally of three types.

1.General damages include those for pain and suffering.

2. Special damages include past, present, and future medical expenses,
loss of income, wages, and profits and funeral expenses.

3. Punitive damages are awarded for gross negligence.

======================================================

From: "faith_gibson" <ronnie@...>
Date: Sun Jan 30, 2005  8:55 am
Subject: Response to Carrie, Vision of a brighter future

Original message from Carrie on Jan 29, 2005:

Carrie wrote: I didn't realize it was a contest.

Faith's reply: nor did I.

Carrie: I have talked to one midwife already that is sorry she voted
yes without reading the proposed document.

Faith: She could change her vote or call me and discuss her concerns.

Carrie: What we really need is an acceptance of the national standard
for midwifery, either that of the ACNM, MANA or the newly created
NACPM standards.

Faith: Adoption of a "standard of care" by the MBC is required by law;
it's not something I invented and the time line for this is neither in
my hands or their. It's already been 2 ½ years. Dr Fantozzi promised
the Board that he would to bring this regulatory marathon to a close
ASAP.

Should the CCM standards and guidelines become the identified standard
in California (which is statistically very unlikely, since ACOG and
the CMA are lobbying hard against it and their lawyers are experts in
OAL law), it would not mean that any of us are rejecting or failing to
accept the national standards. If fact, the CCM standards are actually
a reprint (with some editing) of the College of Midwives, British
Columbia standards and track remarkable well with the MANA standards.

Carrie: Legally, as I have recently read, there is legal precedent
for the disallowance of a regional standard in favor of a national one.

Faith: the type of legal precedence you refer to relates to civil
litigation, not OAL regulations for licensed midwives. It also was the
result of trying to escape the requirements of the national standard
of care by watering down their region's standards. Neither of those
things apply to our situation.

Carrie: No one I have spoken to is 100% happy with the CCM document.
It puts what should be practice specific protocols into law.

Faith: There are virtually NO protocols in the CCM document except for
the ones each individual midwife would develop for herself.

Now for the "Nobody is 100% happy". Well, of course, and that includes ME

But let me remind you that as recently as December 13th you said:

were there things we wanted re-written? yes
were there things we would have left out? yes
were there things we would have added? only a few
were there things we absolutely couldn't live with? NO

It the same for me -- things I'd re-write, things I'd leave out, a few
things I'd add but nothing I absolutely couldn't live with.

Carrie: They wont be easy to change there, … it could create real
hassles for us in the future.

Faith: Yes, but the process to change a regulation is the same
process we are currently using, it is a "local" process that we have
every good change of making work for us. Unlike the issue of physician
supervision, which is "black letter law" (that is LMPA statues) which
the MBC has no ability to change or redefine, regulations passed BY
the MBC can be changed BY the MBC.

The question is this:

Do we reject this "but its NOT PERFECT" opportunity to avoid the
possibility of a `hassle' or because we are afraid that something
unforeseen might occur in the future?

Or do we take the best we can negotiate at present and continue to
build on our success and correct our problems as we go?

The process of building on our successes is how we have developed a
workable system for the LMPA despite its supposedly "fatal" flaws.
Eight years after its implementation, no LM has been disciplined for
practicing without a physician supervisor. We`re doing OK with the
Medical Board and I expect us to do even better in the future.

Carrie: I think all CA midwives and consequently the families they
serve stand to endanger their practices and possibly their livelihood
by accepting your document without comment.

Faith: That's a possibility but not a probably. The much greater
possibility, in fact, the probability (according well-informed and
reliable Medical Board sources) is that all of us AND all the families
we serve will be endangered if they don't, since the Board will
predictably revert to the earlier lists of medical restrictions and
other prohibitions such as no VBACs, no postdates, no PROM, no women
over 40, etc.

Carrie: It is not a document I can personally live with, nor do I
think it is a document we should have to have as law.

Faith: Carrie, I don't think that spending a lot of time on this last
comment is helpful to either of us. Let me just make one important
point here and then I want to close with a very positive vision.

When your CAM region decided that: "what we really needed to do was to
NOT support the document at all", all CAM and all other midwives lost
something very crucial – protection from our historic adversaries –
A_COG, the CMA, other organized medicine groups and the trial lawyers
lobby.

Fighting the CCM standard of care is what A_COG and the others are
already doing. You really don't have to bother. Wild Indians are
stocking the wagon train, prepared to fight to the death, and its only
a matter of time before they attack. CAM's official leadership
response so far has been to circle the wagons, order everyone to get
out their guns, to turn around, to aim straight into the middle of
their own group and then to fire.

What this means is that nobody is minding the store because instead of
protecting ourselves against the unfair power equation of organized
medicine, we are arguing about adoption of a document that "nobody
thinks is 100% perfect". We need to regroup, because the one thing
that is certain is that organized medicine is out there and they are
working with a powerful single focus and single purpose AND an
unlimited budget AND world class lawyers AND long experience in
getting their way.

So instead of shooting at each other (a strategy known in the nuclear
war terms as "mutually assured destruction") let me tell you my vision
of the future.

In that future, the CAM membership realizes that they need a
professional, LM-only division, without the unwieldy burden of
consensus so that responding to MBC politics in "real time" becomes
possible. This professional subgroup would operate on a simple
majority vote on routine business and a super-majority (60%) in regard
to topics such as standards and guideline. Under these improved
circumstances, the greater flexibility would permit the professional
division to develop multiple creative approaches to the issue of MBC
liaison and legislative lobbying.

You and I know that these roles are a full time job, one I have been
performing for free, supporting myself on income generated by staying
up all night with women in labor. But I'm getting old and cranky and
frankly, it's not a fair burden to ask of others, especially those who
also have the obligations of a younger family.

What's needed here is the voluntary contribution of professional dues
from each practicing midwife in an amount that would permit CAM's
professional division to hire a full time liaison / lobbyist. That
person should be YOU. Let me say this again – CAM's professional
division should engage your full time services as a professional
representative for LMs.

Personally, I suggest that each LM who delivers more than 15 babies a
year contribute the equivalent of the fee she charges for one birth
each 12 months. When I was the administrator of the ACDM professional
liability consortium, midwives doing 12-15 births per year paid $1800
a year, 3 years in a row, for malpractice insurance. Some paid as much
as three thousand dollars. Our tiny little group of 51 midwives
generated a total of $113,000 in premiums for our last year (2001). So
the money is there if people wanted to go that route.

As for the particulars of the job, I know a lot about how to succeed
in it and am happy to tell all. I've devoted myself night and day,
with a single focus and a single purpose, to this task since 1993.
Success is not `ego', its months and years of sitting in Medical Board
meetings, providing patient "labor support" for the Board members.
This is really the art of midwifery, abilities we all have and all
use, in which one reaches deep down into resources we didn't know we
had so that we could listen patiently, watch with our educated eye and
when the time was just right, gently encourage, urge, cajole, seduce,
beg or sweet talk someone on to an important personal victory, to do
something they feared, that may be difficult, that might take a long
time but that is ultimately very rewarding and serves an important
social purpose. (Oh yes honey, I know it hurts, it's the hardest, most
painful work you'll ever do in your whole life, now just give me a
little more push, yes, that right, ….um-hum, good, good, good, …. oh
best push yet, now just a little more – why it's a beautiful healthy
baby that looks just like you and your husband and you did so good,
you did all that hard work all by yourself, I'm so impressed, you just
did great!)

California midwives need leaders that are calm, sure of themselves,
knowledgeable, have vision and can urge them on, to stretch out the
possibilities, just the way we ask mothers to relax, trust the
universe and stretch out their perineums. The universe is kind to
mothers and also to midwives. You're an excellent midwife, you have
the requisite leadership abilities, great academic credentials,
research skills and lots of experience that midwifery would benefit from.

But for this kind of work to work for you, you need to be paid a
professional full time salary and frankly, I think midwives need to
realistically acknowledge that there is a real financial cost to being
a professional. Think of it as "livelihood assurance". Better to pay
for good professional representation that helps us ALL avoid trouble
than for each of us, one by one, to have to fork out for a good
lawyer. Just ask Alison about that one.

Think about these ideas for a day or so before responding.

California midwives need YOU! And we all need a more effective, more
responsive system, tailored to the real time needs of the Medical
Board here in the 21st century. We are a long way from Connie and
Marie's kitchen in San Jose, in 1979. We're grownups now and can
accept that in the real world, you have to pay to play.

With much affection I bid you goodnight.

==================================================================

From: "faith_gibson" <goodnews@...>
Date: Mon Jan 31, 2005  8:43 am
Subject: Answering questions and clarification on personal guidelines

I was wondering if anyone out there has questions about specific
aspects of the CCM Standard of Care.

For example, I intended to add the text below to Section One – I
(Practice Policies and Guidelines), but the MBC would not permit any
changes until after the February hearing.

I still think the intended clarification is helpful, as otherwise it
sounds SO burdensome to have personal practice protocols for EACH
clinical area of practice, when in fact, its just a matter of picking
out (or designing your own) chart form or consent which matches your
routine practices and personal preference.

Here is the original part of the material as published in subdivision
C.

"The midwife shall establish policies and/or guidelines for each
practice area, which shall include but is not limited to, the
antepartum, intrapartum, postpartum and newborn periods."

Here is the new clarification, which will be added later to the
"Commentaries" section:

"The usual method for establishing and implementing clinical
guidelines for routine care is thru the adoption of, or development
of, appropriate chart forms, informed consent documents and other
appropriate documents used routinely during each of these periods of
care.

Standard chart forms function as an aid to the caregiver to ensure
conformity to the care plan as well as completeness of clinical
assessments."
======================================================================
I'll be working on the CCM testimony for the rest of the week but
will
be done by Thursday and so could take other questions starting Feb.
4th.

Warm regards, faith ^0^
=====================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 6, 2005  11:46 pm
Subject: FHTs but NOT related to regulations or the MBC Hearing //

I am preparing 'clarifying comments' for section 4 (Commentaries) of
the CCM document. The reason is the large number of midwives who have
expressed concern about the so-called 'schedule' for FHTs. There is no
required schedule (hense the use of the word "recommended" instead),
since the real criteria is based on force and frequency of uterine
contraction and stress to the baby, not on cervical dilation.

However, many are afraid that these 'recommendations' will impose a
rigid structure that inappropriately displaces the clinical judgment
of the midwife. The notation "as indicated" actually refers to the use
of the clinical judgement of the LM to take FHTs more or LESS often,
based on the situation (e.g., the mother is sleeping!)and other factors.

So here is text of the "Commentary" for section four.
My question is one of clarity.

warm regards, faith ^O^
======================================================================

The schedule for monitoring FHTs is often associated with the stage of
labor as identified by the practitioner. However, labels such as
`latent' or 'active' labor or `second stage' are merely proxies for
the crucial criteria. The physiological determent for how often fetal
heart tones need to be monitored is the quality of the labor in
conjunction with the specific situation, such as overall time the
mother has been in ACTIVE labor and other circumstances effecting
maternal // fetal reserves. Quality of labor is defined by three
specific criteria -- force, frequency and length of the uterine
contraction (UC) pattern.

Stress to the healthy term fetus is a function of force and frequency
of the UC pattern. UC that are long (over 60 seconds), strong (unable
to indent uterine wall at the apex of the contraction for 30 or more
seconds) and close together (under 3 minutes) expose the unborn baby
to more stress and to less recovery time. This forces the
maternal-fetal physiological unit to function at the high end of its
capacity where as UC that are mild, infrequent and brief does not have
this effect.

Stage of labor as judge by cervical dilatation can be discordant with
the contraction pattern. While characterization of labor stage is a
useful guide in many areas of midwifery care, such as notifying the
second call midwife and preparing for the birth, the most appropriate
guide to the frequency of fetal monitoring activities is the stress to
the physiology of mother and baby. The notation "as indicated" assumes
that the clinical judgment of the LM will adjust the frequency up or
down and choose the form of fetal monitoring based on the force,
frequency and length of the contraction pattern and other factors that
directly or indirectly influence well being and potential reserve of
the maternal-fetal physiology.

==============================================================

From: "faith_gibson" <goodnews@...>
Date: Mon Feb 7, 2005  7:30 am
Subject: ACOG & AWWOHN schedule for FHTs

Sue,

ACOG and AWWOHN do have published schedules for FHTs – q. 1 hr in
latent, q 30 mins in active and q 15 min in second stage. None of
these intervals is based on or modified by force and frequency of the
labor pattern or the actual potential for fetal stress. Instead they
are predicated on an assumption that all women who are 4 or more CMs
dilated are in an active progressive stage of labor with long, strong
and frequent UCs. Unless community midwives publish a specific
guideline of our own, we are vulnerable to being judged by obstetrical
or nursing protocols.

So I stretched out the AGOC and AWWOHN numbers by adding some
intermediately "phases" of labor and noting that the clinical judgment
of the midwife could modify any recommended schedule " as indicated",
based on force and frequency of the labor pattern, especially, a very
`back burner' type of pattern in which nothing much was happening,
even though the mother's cervix was moderately dilated.

When you read studies on home-based birth care (for example, the one
published in the Canadian Medical Journal in 2002) or talk to the
Medical Board about the bulk of complaints about LMs, both sources
identify fetal distress. They both observe that community midwives
apparently do not reliably recognize the gathering storm of fetal
distress nor do they respond appropriately to it in a timely manner.
If that is true, it is something we can as a profession can (and
should) do something to remedy.

Totally aside the current controversy about the MBC regulations and
the CCM standard of care, the Medical Board is pursuing a new
amendment to the LMPA that will require every midwife to report every
instance of morbidity and mortality, including any emergency
transports and all poor outcomes. One hopes that it will be a very
short list and that good clinical skills in regard to the
appropriately timing of FHTs would be helpful I preventing preventable
problems.

Warm regards, faith ^O^

=================================================================From: "faith_gibson" <goodnews@...>
Date: Tue Feb 8, 2005  12:23 am
Subject: Re: Getting past the drama

My personal request is for a truce. In less than 2 hours the deadline
for submitting written testimony will have passed. All any of us can
do now is wait and hope for the best. I'm at peace about this topic,
ready to accept the Medical Board's vote and the OAL's final verdict.

I thank everyone for being so responsive and involved and expressing
yourselves so fully. Lets look to the future now. At least for me,
that includes getting back to normal life and civil discourse amongst
ourselves.

Whether the CCM document is directly incorporated into regulation or
not, it will continue to function as a source of information for
consumers and a guide to midwives in regard to standard of care issues.

Last December I started a new section entitled "Commentaries" to
provide clarification on word definitions and specific items or topics
that have generated a lot of questions or resulted in a
misunderstanding. So far there is a "Clarifying Comment" on emergency
transport by private car and by paramedics, one explaining the how and
why of charting the "intention of a planned home birth" and the most
recent work-in-progress on fetal monitoring based on the fetus'
exposure to labor-originating stress (rather than the clock and `stage
of labor' used by ACOG). Another area to be addressed is charting and
how `current is current'.

For example, a midwife friend recently expressed her concern that she
wasn't able to chart events during the last part of 2nd stage, the
delivery and immediate PP/NB care as the other midwife was not able to
get there in time and things were very hectic. She was afraid that her
charting might be considered substandard but in fact, it is a common
problem in medical care and one with a recognized `convention'.
Medical professionals are not expected to stop in the middle of a code
or when treating a heart attach or auto accident victim to chart
minute by minute. The convention only requires you to chart when your
immediate duties are completed, usually within a few minutes or a few
hours but for midwives, it may be the next morning before she is awake
enough to get it all recorded. Standard of care is always based on
common sense, since it is what practitioners commonly do in the same
or similar circumstances.

The point of all this is that many sources are involved in coming to a
legal conclusion about "standard of care". It is always something of a
work in progress and this is one area where every single midwife can
contribute her concerns and her ideas in the process of arriving at a
general consensus that we all are relatively comfortable with. Section
4 (Commentaries) is still part of our standard of care, still
contributes to the understanding of all parties.

When I was the administrator for the malpractice insurance consortium,
I collected a written survey from each ACCM applicant that included
questions on areas like VBAC and breech. Had we ever had to go to
court to defend any of our members, these records would have been
submitted to the court as evidence of a distinct midwifery standard of
care that included providing care to VBAC mothers, as would peer
review studies, textbooks and information on the autonomy of the
childbearing woman and informed refusal, etc.

So the CCM is only a start, it is not a "finish". And its an on-going
process that includes all California licensed midwives. And i'd be
delighted to hear from LMs that desire clarification on specific
points, as the record this produces is part of the process.

much affection, faith ^O^

===================================================================

From: "faith_gibson" <goodnews@...>
Date: Sat Feb 12, 2005  9:27 am
Subject: Realistic apprasial of MedBd's enforcement powers

 

An unrealistic apprasial of the Medical Board's power seem to be
widespread. Bottom line is that the MBC can't just "go after
midwives". Having an articulated standard of care won't change that
one way or the other.

My information come from attending Board meetings for more than a
decade, as well as consulting for defense lawyers in cases against
both licensed and lay midwives and a case against a homebirth
MD-midwife. I read all the documentary evidence for all these case,
including the Board's accusations, a copy of the midwife's chart and
the opinions of all the expert reviewers. From that I have an informed
opinion about what the Board can legitimately do and equally important
what it can't or won't do.

The Medical Board's legislative mandate ONLY authorizes them to
investigate specific complaints from a patient, family members or
another professional. The specific nature of their investigation is
limited to the specifics of the complaint. This restricts them to
investigating the care provided to that one particular patient. They
cannot just arrive at the LMs office and go through all her records,
looking for substandard charting or other paperwork problems like
failure to provide a professional disclosure or to chart FHTs on some
preordained schedule.

For example, in the case against Alison Osborn, the Board could only
legally obtain (and use) the chart for the mother's prenatal care, the
intrapartum records and the opinion of the physician at the hospital
where the baby was transferred after delivery.

Also I must mention the obvious – that is, California's budget crisis.
The Medical Board is on Gov. Arnold Swartznagger's list of board to be
repealed and replaced by a big, all-purpose Department of Consumer
Affairs bureau that would investigation all complaints, including
those against auto repair shops and cosmetologists.

It's true that the ratio of LMs who have had complaints filed and
investigated is hugely disproportionate compared to doctors and all
other MBC licentiates. But that is more a factor of the hostility of
obstetricians against HB midwifery and the physician supervision mess,
combined with a legal requirement for the coroner to report all OOH
deaths and any that occur within 24 hours of hospitalization. The LM
program costs the Board far more money than they receive in licensing
fees and renewals. They are under extreme pressure by Senator
Figueroa's office (also a result of SB 1950) to clean up their act in
regard to physician discipline, which means spending MORE money on
disciplining doctors. They would really like it if the LM program
wasn't wasting their time and their money.

While there is a wide difference of opinion about what a `good' case
includes, the Board only pursues cases that have technical "merit",
that is a bad outcome, a death or a complaint by a patient who is
willing to testify in court. They often pick cases based on having the
kind of evidence that can effectively compel the defendant to plea
bargain, this saving the Board the cost of a hearing. It should be
noted that poor charting is one of the most frequent reasons that a
midwife is unable to effectively defend herself.

It passes my mind daily that the MBC could twist things and use our
own best stuff against us. However, in the face of a dead or damaged
baby or a personal attack against the midwife by one of her own
clients or a moderate risk transfer (VBAC, breech, twins, PROM,
post-dates, GBS+), the Board already has everything it needs to pursue
a case. While its true that aspects of the CCM document could
conceivably be used against us, it is also true that the plain
language of the regulation itself protects us (… the client has the
right to refuse that recommendation as well as any other treatment or
procedure, if the client makes a written informed refusal, the
licensed midwife may continue to provide midwifery care to the
client). In addition, the CCM section that acknowledges the legality
of midwifery care to VBAC, etc actually PROTECTS midwives because it
prevents the Board from having a slam-dunk case. The case against
Alison would never had occurred under these regulations, nor the
several cases relating to VBAC transfers.

I too worry every time I transfer someone into a midwife-unfriendly
hospital or have to deal with a hostile OB or L&D nurse. However, I do
genuinely believe that the CCM standard of care as a document
"approved" by the Board give us protection at the level of the angry
OB and also at the level of the Board, should said angry OB make a
complaint.

And yes, we have to effectively eliminate the "poison pill" of
physician supervision. Over the last 6 years (since Alison's case) I
have made several forays into the legal area in an effort to start a
class action suit. I won't bore you with details except to say that
good legal advise convinced me that it was CHEAPER, EASIER and FASTER
to negotiate a legislative remedy than to fight out a 1 to 3 million
dollar law suit that may take ten years and that we may still loose.

That how Frank Cuny and his organization came to get involved in
midwifery legislation (remember SB 1479 originally was a law to repeal
phys. supervision and replace it with collaborations). The next step
in the legislative plan, after passage of these regulations, is to
approach the legislature again with new ground for a win-win solution.

By having a stipulated standard of care that is consistent with the
other states that license midwives under collaborative instead of
supervision (which is ALL the other states with direct-entry
midwifery), it is possible to advance the idea of regulatory oversight
instead of physician supervision.

From the standpoint of the Legislature, it is ridiculously easy to
document that supervision is (1) a complete historical failure –
virtually no midwives have ever practiced under phys. supervision (2)
totally unworkable in the present and future (with letters from
malpractice carriers forbidding docs to provide supervision or even
give emergency advise) and (3) unnecessary now that we have an agreed
upon standard of care, thus eliminating the "role" of the supervising
doctor to define how the LM practices.

I am confident that we will be able to find a legislative solution
much easier than litigation and that we can expect to succeed in the
next 2 or 3 years. And yes, we need to fund an all-LM organization
(see my earlier post to Carrie titled "Vision for a Brigher Future").

=================================================================

From: "faith_gibson" <goodnews@...>
Date: Sat Feb 12, 2005  9:45 am
Subject: reposting of message #16 -- to Carrie, funding for LM politics

Originally response to Carrie:
======================================================================
.... nobody is minding the store because instead of
protecting ourselves against the unfair power equation of organized
medicine, we are arguing about adoption of a document that "nobody
thinks is 100% perfect". We need to regroup, because the one thing
that is certain is that organized medicine is out there and they are
working with a powerful single focus and single purpose AND an
unlimited budget AND world class lawyers AND long experience in
getting their way.

So instead of shooting at each other (a strategy known in the nuclear
war terms as "mutually assured destruction") let me tell you my vision
of the future.

In that future, the CAM membership realizes that they need a
professional, LM-only division, without the unwieldy burden of
consensus so that responding to MBC politics in "real time" becomes
possible. This professional subgroup would operate on a simple
majority vote on routine business and a super-majority (60%) in regard
to topics such as standards and guideline. Under these improved
circumstances, the greater flexibility would permit the professional
division to develop multiple creative approaches to the issue of MBC
liaison and legislative lobbying.

You and I know that these roles are a full time job, one I have been
performing for free, supporting myself on income generated by staying
up all night with women in labor. But I'm getting old and cranky and
frankly, it's not a fair burden to ask of others, especially those who
also have the obligations of a younger family.

What's needed here is the voluntary contribution of professional dues
from each practicing midwife in an amount that would permit CAM's
professional division to hire a full time liaison / lobbyist. That
person should be YOU. Let me say this again – CAM's professional
division should engage your full time services as a professional
representative for LMs.

Personally, I suggest that each LM who delivers more than 15 babies a
year contribute the equivalent of the fee she charges for one birth
each 12 months. When I was the administrator of the ACDM professional
liability consortium, midwives doing 12-15 births per year paid $1800
a year, 3 years in a row, for malpractice insurance. Some paid as much
as three thousand dollars. Our tiny little group of 51 midwives
generated a total of $113,000 in premiums for our last year (2001). So
the money is there if people wanted to go that route.

As for the particulars of the job, I know a lot about how to succeed
in it and am happy to tell all. I've devoted myself night and day,
with a single focus and a single purpose, to this task since 1993.
Success is not `ego', its months and years of sitting in Medical Board
meetings, providing patient "labor support" for the Board members.

This is really the art of midwifery, abilities we all have and all
use, in which one reaches deep down into resources we didn't know we
had so that we could listen patiently, watch with our educated eye and
when the time was just right, gently encourage, urge, cajole, seduce,
beg or sweet talk someone on to an important personal victory, to do
something they feared, that may be difficult, that might take a long
time but that is ultimately very rewarding and serves an important
social purpose. (Oh yes honey, I know it hurts, it's the hardest, most
painful work you'll ever do in your whole life, now just give me a
little more push, yes, that right, ….um-hum, good, good, good, …. oh
best push yet, now just a little more – why it's a beautiful healthy
baby that looks just like you and your husband and you did so good,
you did all that hard work all by yourself, I'm so impressed, you just
did great!)

California midwives need leaders that are calm, sure of themselves,
knowledgeable, have vision and can urge them on, to stretch out the
possibilities, just the way we ask mothers to relax, trust the
universe and stretch out their perineums. The universe is kind to
mothers and also to midwives. You're an excellent midwife, you have
the requisite leadership abilities, great academic credentials,
research skills and lots of experience that midwifery would benefit from.

But for this kind of work to work for you, you need to be paid a
professional full time salary and frankly, I think midwives need to
realistically acknowledge that there is a real financial cost to being
a professional. Think of it as "livelihood assurance". Better to pay
for good professional representation that helps us ALL avoid trouble
than for each of us, one by one, to have to fork out for a good
lawyer. Just ask Alison about that one.

California midwives need YOU! And we all need a more effective, more
responsive system, tailored to the real time needs of the Medical
Board here in the 21st century. We are a long way from Connie and
Marie's kitchen in San Jose, in 1979. We're grownups now and can
accept that in the real world, you have to pay to play.

With much affection I bid you goodnight.
faith ^O^
======================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  6:11 am
Subject: Re: MB meeting info

--- "Lori Luyten" <LoriBlessedBeginnings@m...> wrote:
>
>I've only attended 2 MB meetings and both times I was given a time
frame as to when they'd be addressing midwifery issues. Does anyone
know the particulars for this meeting? Thanks, Lori Luyten, LM, CPM
======================================================================

The public hearing is the 4th of 14 agenda items. The hearing is
scheduled to start at 9AM. The entire DOL meeting must end by noon, as
all Board members break for lunch before the large general board
meeting that starts at 1:30 pm. Several of the other items (#5 thru
#13)on the agenda are a big deal (especially the legislative report
from Linda Whitney and Plastic Surgery report). Its the Board's legal
obligation to address the rest of the agenda items before the noon
deadline, so they will limit the Mfry hearing, probably to 50-75
minutes.

Those attending the hearing will be asked to sign in if they wish to
speak (includes ACOG, trial lawyers,lobbyists, consumers, etc). The
number of those signed up to speak will be divided by the number of
minutes (usually about 30-45 minutes) alotted for oral testimony.
Generally that comes to under 3 minutes per person. The rules for oral
testimony require that any anyone speaking only address NEW
information or opinions that are different than their written
testimony and does not repeat earlier oral testimony. Dr Fantozzi is
rather brusk to the speaker if this rule is not observed.

As for the Board's opinion on the MANA standards, their answer was the
equivilent of "over our dead body". This opinion includes all the
physicians on the Division of Licensing panel (Drs Fantozzi, Karlan,
Gatnick and Bolton, who are the members seated for the hearing), as
well as the Board's executive director, Dave Thorton. The Board's
absolute and total refusal to adopt a midwifery 'standard' that was
not specified is the reason that the Board let the original hearing
(held Aug 1, 2003) die by refusing to vote on it for more than 365
days.

Mr. Thorton (former chief of Enforcement for 24 years b4 being
appointed director)was standing in the back of the room during the
last Midwifery Task Force meeting on Nov 5th in SD. He signaled Dr
Fantozzi to bring the MTF meeting to an abrupt end at the mention of
LMs attending breeches and twins. It was that interaction between Mr.
Thorton and Dr Fantozzi that triggered Dr Fantozzi to direct me and
the Board's senior counsel, Anitia Scuri, to sit down immediately to
write part 2 of the regulation on breeches and twins.

This extemporanious meeting ultimately included all the other midwives
who had come for the MTF meeting, CAM's lawyer Tim Chambers and Ed
Howard, the lawyer from Figueroa's office. I had copies of ACOG's
policy statements on "Informed Refusal" and conflicts in the
maternal-fetal relationship, which i gave to Anita as evidence that
childbearing women had the ethical right to decline medical
management, and that this was even recognized by ACOG. As a result of
Anita's willingness to push the envolope, we actually came to the
direct opposite conclusion to the one that Mr Thorton originally
intended, which was to EXCLUDE breeches and twins. You've got to
believe in miracles on this one!

As for the ACNM standards, the issue is the same, as they (like MANA)
don't identify any guidelines or minimum practice requirements. The
Medical Board is only willing to recognize a midwifery-based standard
of care (instead of medical one)if they also get what they want -- an
articulated foundation for midwifery practice.

If the Office of Administrative Law sticks to a very narrow
interpertation of the term "standard of care" and thus rules against
the inclusion of guidelines and minimum practice requirements, the
Board will ask Senator Figueroa or another legislator to carry a bill
amending the LMPA so that the Board clearly has the authority to pass
what they believe to be meaningful regulations -- standards,
guidelines and minimum practice requirements that are broad as well as
deep. Personally, i think we'd do better to stick with the CCM
document but whatever will be, will be.

warm regards, faith ^O^

===========================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  6:22 am
Subject: Standards are not perfect

"Susan Gill Blessed Beginnings" <blessedbeginnings@c...> wrote:

>>> I'm not sure everyone is absolutely convinced Faiths standards
are perfect..............

Reply from faith: INCLUDING faith, who is absolutely SURE they aren't
a perfected document!

warm regards, ^O^

==========================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  7:06 am
Subject: Re: Questions // you approciation is appreciated!

>>> I also want to say thank you very much to Faith, Renee, Diane and
Claudia for taking the time to address my specific concerns so late in
the evening. > Lori

Your appreciation is gratefully accepted.

warm regards, faith ^O^

============================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  8:14 am
Subject: Re: MB as a regulatory agency

Diane Holzer <midwife@l...> wrote:
>>> Why do you think that the Standards that are adopted need to
describe exactly what we do? No other practitioner has this in
regulation.......

reply f ^O^: No other practitioner is mentioned in SB 1950, which
specifically directs the MB to adopt regulations defining the
appropriate standard of care of midwifery.

> why wouldn't it be a good strategy to argue that what is meant by a
> standard of Care is the broad statements, this is the generally
agreed definition of that term.

f^O^: We have only been arguing that for 2 1/2 years. Its been about
as successful as trying to get the Bush administration to acknowledge
that Sadam was not responsible for the 9/11 tradegy.

> So is it that you think that we as midwives need these things in
> regulations to keep us safe?

f^O^: The issue isn't one of midwives 'needing these things', its a
matter of the the Medical Board needing an identified and specific
definiiton in order for them to feel that it is "safe" for them to let
midwives be midwives. As for the 'safety' of midwives, an articulated
standard of care that acknowledges the appropriateness of LMs
providing care to VBAC, PROM or GBS+ women and other moderate risk
situations greatly reduces the likelihood that LMs will get
investigated or prosecuted.

>>>I don't understand why we shouldn't argue for the generally
accepted definition for standards and see if we can't get that
accepted? It seems ultimately the best thing for all of us in our
practices. This hasn't been tried yet.

f^O^: Oh contrare -- we have been arguing for years and rejected
soundly for years. Since this law was passed in July 2002 there has
been no less than 6 Medical Board meeting and i have written no less
than 50 pages worth of letters and testimony. They said NO. What part
of N-O don't you understand?

>>>I know Fantozzi has an idea of what he wants but he also wants it
to be done and if we all testified to wanting those standards, maybe
he would go for it.

f^O^: "We" aren't alll going to testify that we want to block the
current regulation and replace it with "something" else that at
present doesn't exist. The majority of LMs do not actually support
that position (as demonistrated on this list tonight).

>>>> And if he doesn't, we get a task force to create something we all
can agree to.

f^O^: The midifery task force (MTF) is a hard-won concession of the
Medical Board and only came about becasue i had a very long (but very
polite) temper tantrum for several years (which included talking to a
reporter who was writing a story about the board) about the complete
lack of any forum for dealing with licensed midwifery.

If we give the Board a black eye in public or expose ourselves are
being totally unreasonable, there will be no more MTF meeting. There
is no legal foundation for the MTF and nothing we can do ask sweetly
for their cooperation. At this point, its a safe bet that Dr. Fantozzi
will just revert to the list of NO-NOs that he proposed before. He is
incredulous that midwives would suggest a non-solution like standards
without any definition.

Now i have a question of my own. Since neither you, Elizabeth, Joan
Green, Leah or Carrie have had broad and/or deep experience with the
Board,its history and the legal background for their regulatory
function, what exactly do you base your assumption on that would
leadus to believe that we can get the Medical Board to do what ever we
want it to do and/or that "we" LMs would all equally agree upon?

warm regards, faith ^O^

======================================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  8:44 am
Subject: ACNM document poll

Claudia Glass <karate_grrrl@y...> wrote:

> Please respond with "I support" or "I do not support"
> the recommendation of the ACNM documents. Also let us
> know your professional title (LM. unlicensed midwife,
> student midwife, etc) and whether you are a CAM member.

reply: I do not support the ACNM document, I am a licensed midwife and
a CPM. I am no longer a member of CAM.

respectfully, faith gibson, LM, CPM

=========================================================================From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  7:06 pm
Subject: The Right Use of Fear

An earlier post listed several state licensing laws that have been
usurped and turned midwife-UNfriendly or cases in which the midwives
made a deal with the Devil in order to get licensing laws passed and
now they regretted it (example: Tennessee's law has consultation
instead of supervision, which is good, but then requires the OB to
sign off each on chart, which is bad).

The purpose of the earlier writer was to convince LMs that we should
fight the MBC's current regulation because it too might be used
improperly in the future. There are two things to say about this
negative motivation by fear.

First, it is totally illogical to say `NO' when one's regulatory
agency meets one half way based on the fear that they COULD, they
MIGHT, misuse the advancement. Of course they `could', but there are
an infinite number of other possible outcomes. Saying `no' to
everything all the time is a symptom of those who suffer from
post-traumatic stress disorder or childhood sexual abuse (I know too
much about both). It seems like the only way to protect oneself
against overwhelming power but it also keeps one stuck at a very
dysfunctional level and perpetuates victimization.

That kind of paralyzing fear is understandable but we must
collectively support each other so we, as individuals and as a
profession, can get past the immobilization it engenders. Fear is not
all bad, but must be used to mobilize us into effective,
self-protective action. As California LMs know, we would really have
shot ourselves in the foot to say `no' to the LMPA. It wasn't perfect
but it turned out far better than our worst fears and it leaves us
with the ability to perfect the licensing law over time.

Had we chosen instead to remain as lay midwives, fearing criminal
arrest and fighting criminal prosecution, we would never of had the
chance to get the 2000 amendment by Figueroa that negates the Bowland
Decision by acknowledging the competent woman's right to have control
over the manner and circumstances of normal birth. For midwives, the
amendment acknowledges an alternative way to provide effective medical
interface during pregnancy, labor and emergency arrangements. Had we
stayed as lay midwives, the opportunity to materially improve our
circumstances via the Alison Osborn decision would never have happened.

Fear of abuse in the future is a realistic problem but it is a much
greater opportunity to advance midwifery for California LMs and the
rest of the US. First, all LMs must continue to be at least part-time
players in the game of licensing, just as all citizens in a democracy
must continue to participate in the democratic process in order to
protect the freedoms. Midwives need to either know and personally
understand the legal and constitutional foundation for normal
childbirth services or to financially support someone who does know
and understand them.

The problems alluded too earlier in which other jurisdictions have
misused the licensing law is the very reason that we must constantly
work to protect our current status and work constantly to improve it,
not only for ourselves but for the right of women who make
medically-unpopular choices (many of who are survivors from PTSD or
childhood sexual abuse)so they continue to have access to the safety
net of experienced midwifery care.

So once again, I refer LMs to the last half of message #16 (Vision of
a Brighter Future), which I reported as message #166. For the last
decade member support of CAM thru dues had been directed almost
exclusively to the annual CAM conference, using the lion's share of
organizational resources in time and money for that purpose and
leaving only stems and seeds for professional oversight activities. We
need to re-examine that situation and to acknowledge that LMs do have
the money to have a professional organization if we choose to pursue
such an opportunity (and CAM can still host an annual conference).

In closing i remind midwives of the courage of Alison Osborn to go to
the mat, with no guarantee of success, to spend over $50,000, all in
an effort to make the LMPA and our relationship with the Medical Board
of California work for LMs and the mothers we serve. There are others
out there that have fought and won in regard to inappropriate MBC
investigations (they know who they are!) and this helped all the rest
of us. I personally know of an instance in which an LM agreed to
surrender her license in order to keep from going to court and risk
getting a ruling that would set a really bad precedent for all other
LMs. Courage is all around us.

In spite of the fact that we have been victimized in the past (and may
suffer unfairly in the future)we are not helpless victims. There are
many reasons to be hopeful. My vote for the MBC regulation is a vote
for a better and brighter future for the childbearing women of
California who need continued access to safe, effective professional
midwifery care.

Warm regards, faith ^O^

=================================================================

 

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  9:46 pm
Subject: Re: re: MBC meeting // why everyone should sign up to speak

 Donna Fritz <socalmidwife@y...> wrote:
If needed, I will toss my hat into the ring and speak. Just want to
be careful that we aren't sounding too opposing--both to the Medical
Board AND each other. Also, we don't want to be repetetive, as the
board won't honor our comments if we are.
======================================================================

Everyone who goes to the meeting should sign up, even if you don't
have anything to say. Just pass when they call your name and offer to
cede your time to the next midwife speaking. When lots of people sign
up it cuts down the time that ACOG and CMA have to attack the
midwifery model of care.

warm regards, faith ^O^

===========================================================

From: "faith_gibson" <goodnews@...>
Date: Sun Feb 13, 2005  9:50 pm
Subject: Please forgive repeated spelling goofs -- i'm a poor typist

I hate to type, i'm an awful speller and have a keyboard that is
slowly dying, a deadly combination.

So i can only ask for your indulgence in regard to spelling screw-ups
in the subject lines. The last mistake was my third in a row.

sighhhhhhhhh

faith ^O^

==============================================================

From: "faith_gibson" <goodnews@...>
Date: Mon Feb 14, 2005  6:36 am
Subject: Re: MB as a regulatory agency

Carrie <carrielm@s...> wrote:

> I posted some excerpts from, your letter of Aug 04 to CAm re the
> standards issue and you stated that any "standard" adopted should be a
> floor and not a ceiling"

Do you believe that your document fits that description?

Absolutely, the minimum practice requirements are the floor, the midiwfe's
own protocols are the ceiling.

warm regards, faith ^O^

=================================================================

From: "faith_gibson" <goodnews@...>
Date: Mon Feb 14, 2005  8:50 pm
Subject: Re: MB as a regulatory agency

Diane Holzer <midwife@l...> wrote:
>>>> Well i think that all of the aforementioned people, myself
included, have followed these issues closely over the years, attended
board meetings, attended CAM meetings where you and others have given
reports and opinions etc....and i don't consider any of these people
inexperienced in legislative or regulatory issues.

======================================================================

Faith's responses @: Diane, I'm at my whit's end to express to you
the difference between an occasional "attendance" a Medical Board
midwife-related agenda item, in which all the special midwife
attendees get there just in time for the meeting item and get up and
walk out when their agenda item is over as contrasted to the broad and
deep commitment (again best described as "labor support") that is
necessary to actually be politically effective with that agency.

One has to literally devote one's life to the task as a steady
commitment, something like an anthropologist who is studying a strange
tribe and must sit quietly for endless hours observing village life in
order to develop an understanding of the way they think, what their
motives are and to identify the specific `pressure points' that permit
one to have a positive influence over the course of events. One must
learn the foreign language of "MedBd-speak". In MedBd speak, the
absence of "yes" over time equals NO.

If you doubt my long and intense study of the subject matter, peruse
the `legal/legislative' and the `Medical Board of California'
subdirectories on the college of midwives web site. That is only a
fraction of the 43 three-ring binders of letters and legal documents
that I have amassed over the last 10+ years. I am an expert in this
subject and running exactly counter to my informed opinion is
hazardous to both LMs and the families we serve.

@ I'm so sorry if you find my next comment to be offensive but the
lack of any true insight on this topic is making me a little nutty.

@ Your relationship with this entire matter is exactly like the
obstetrician who has never actually seen, much less conducted a normal
birth, never, ever has "labor sat", has no real idea of what it would
mean to have the deep, long term relationship with a childbearing
woman during all the months pregnancy care and all the hours (days!)
of labor and birth at home, but none the less confidently tells the
Medical Board and legislators that THEY KNOW ALL ABOUT CHILDBIRTH
(trust me honey, I'm a doctor!) and they should write our licensing
laws, control our regulations and function as expert reviewer because
they are the real "experts".

@ Both you and Elizabeth and even Carrie have not spent a decade
`midwifing' the Medical Board, in part because each of you spent the
last decade pursing (quite successfully) OTHER important work. What
would you or Elizabeth think if the tables were turned and I suddenly
stepped forward to block your leadership with MANA or to put NMI out
of business and insert my own re-designed midwifery educational
programs instead? By the standards employed by you and Elizabeth, I
too have great credentials for each of these endeavors, after all I'm
a MANA member and I have attended many MANA meetings over the years
and I have just as much innate ability to develop a midwifery
curriculum as Elizabeth Davis (since neither of us have advanced
degrees in post-secondary educations).

@ Yes, you have been involved in legislative matters but in quite a
different context than specifically working with this particular
legislator on this particular topic (power-imbalance with the Medical
Board). You may or may not know just how much Senator Figueroa (who is
the Chair of the Senate Business and Professions committee) has taken
on the Medical Board in a broad and deep manner, not just as a in
regard to the LMPA, nor realize how much that matters in this situation.

You may not realize that one of the most important and far-reaching
amendments to the LMPA is about to occur – a new law (NOT a
regulation) mandating that midwives report all morbidity, mortality
and any emergency transfers. You may not know that the doctor who
initially reviews all complaints against midwives is adamant that the
vast majority of `meritorious' complaints against midwives are NOT
physician supervision or "failure to dot the `I' or cross the `T'",
but rather inability to recognize fetal distress or lack of
appropriate and timely response to fetal distress. You doubtless do
not know (since I haven't discussed it) that one of the reasons there
is so much "stuff" ie. detailed info in Section II about taking fetal
heart tones is because very soon midwives will indeed have to justify
their fetal monitoring (the active verb, not the machine!) each time
there is a bad outcome that is diagnosed by the perinatologist expert
reviewer as related to "fetal distress". Wouldn't it be nice to tell
people ahead of time what they need to know to PREVENT problems and to
successfully defend themselves should such a problems occur?

By the time you and Elizabeth are through mucking around in this
issue, pissing off key legislators as well as the Board, Senator
Figueroa will be happy to carry legislation for ACOG restricting the
scope of practice of LMs and authorizing minimum practice requirements
that will be either written by, or improperly influenced by, ACOG.
Under these circumstances, we will have lost the influence that Frank
Cuny and I have spent so many years, so much money, so much blood,
sweat and tears to develop. I have spent thousand of hours, driven
thousands of miles and spent thousands of dollars out of my own pocket
on this one little `specialty' of midwifery while you and Elizabeth
were flying (reimbursed) to MANA board meetings and hanging out in the
hot tub with the `girls'.

Frankly, I don't care if midwives get to practice `boutique'
midwifery, where every aspect of it is based on the personal
preference of the midwife and fashion de jour of her little clique.
Please note, we will be judged by hard science (emphasis on the
"hard"!), as it occurs in published textbooks, not by those for whom
midwifery is a pleasant hobby and an important social club. What I do
care about is that childbearing women, even those who do not fit the
`mold', continue to have access to the services of a skilled and
experienced midwife and that their unborn babies do not succumb to
fetal distress because midwives are not in the `habit' of taking and
interpreting FHTs at the level necessary to safeguard the fetus.

So come in off the playground of `national' midwifery politics and get
ready to take on this very challenging and full time job of
baby-sitting the MBC store, because nothing else will work.

not so warm in my regards at this moment, but i will get over it --
faith^O^

==========================================================================

From: "faith_gibson" <goodnews@...>
Date: Tue Feb 15, 2005  3:28 am
Subject: Results of Poll // our region#3 have 6 votes against ?? how could

Accoring to Claudia there were:

43 LMs (out of 145 practicing in California, only 51 of whom are
current CAM members)voted to support the ACNM documents
6 LMs who voted NO on the ACNM document
5 supported the CCM document but did not specify in regard to the ACNM
documents (Frankly, i think you can assume these midwives were telling
you they did not support the ACNM document as a replacement for the
CCM standard of care.)

I find these numbers to be unlikely as the region #3 meeting I
attended on Feb 1st had at least 6 (maybe 7)LMs present who voted NO
to ACNM document and Yes to CCM document.

According to your stats, region #3 alone would haveaccounted for the
entire number of "No's". That would leave Jodi Dewhurst, Lori Luyten,
Sue Turner, Susan Gill, Karen Pecora and Donna Fritz who posted on
this list completely out of the count. That is at least a dozen NOs.
(Note that I, Ronnie Falco and Rosanna Davis also voted 'no' on this
list but had already voted "no" in region #3).

How could your numbers be accurate?

This would have required 105% of CAM-LMs to vote (i.e. 43 + 6 + 5 = 54
LM votes) from the 51 CAM-LM members, which seems so unlikely.

faith ^(^
===========================================================================

From: "faith_gibson" <goodnews@...>
Date: Tue Feb 15, 2005  7:54 am
Subject: Re: faith stop // if your will to take your own advise

Elizabeth Davis wrote:

>>>> Faith, As I have not stooped to personal attacks in this
exchange, I¹d appreciate it if you would steer clear of insults and
slander from this point forward.

========================================================================

faith's reply:

Sorry Elizabeth, you got painted with Diane's brush, which is who
wrote the original email message and to whom i was specifically
responding.

As for the issue of working for free for 20 years, too bad to hear
that you too are among the "slave laborers" of midwifery. We both
deserve a Olympic Gold Metal and a fat IRA. Your situation only
reemphasizes the great need to go beyond CAM's single focus on the
annual CAM conferences, which sucks up every body's time and all the
membership money, so we can pay our people a living wage for
representing them as liaison at the Medical Board and with the
Legislature and other important areas like midwifery education.

As for your comment that:

"And although you have done the work, it is not really yours — you did
it on behalf of CAM, as liaison to the medical board. Thus whatever
you do is subject to CAM's consideration." …

I have to dramatically disagree with you. CAM certainly did not pay me
to represent them, or (with one exception) reimburse the expenses of
my travel. I, out of my own pocket, represented the legal and
legislative interests of all LMs and all the women of California as
potential clients of LMs. The idea that my work for a decade was
"subject to CAM's consideration" is mildly interesting but ultimately
irrelevant. What it speaks of is the fallacious idea that CAM invented
and owns all of midwifery, that it alone can lead the way and if
anybody objects, well then, off with their head (i.e. their reputation).

I'm not trying to stir up trouble or insult any of you but at the same
time, the pecking away at the work done on behalf of midwives by me,
Frank Cuny, Anita Scuri, Senator Figueroa and others, work you and
Diane were not interested in doing, just goes on and on and on and on.
You, Carrie, Diane and a few other have yourselves personalized this
issue and you, if you chose, could (and i hope would) reverse this
unfortunate trend.

If you guys are right, why not just sit back and let the nature of
your righteous ideas win out based on their innate superiority?

faith ^(^
====================================================================

From: "faith_gibson" <goodnews@...>
Date: Tue Feb 15, 2005  7:21 pm
Subject: History of MBC & OB politics & Mfry -- Sept 11th, 2004 Letter

Members, Division of Licensing
Medical Board of California
1426 Howe Ave Suite 54
Sacramento, Ca 94303
916 / 263-2365

California College of Midwives
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491

Saturday, September 11, 2004

RE: Retirement from my role as Medical Board / Midwifery Liaison

===============================================================

Dear DOL / Board Members,

This is a follow-up letter regarding my retirement as liaison between
the Board, the Legislature and California Licensed Midwives. As you
know, this role was taken over on July 29th by Licensed Midwife Carrie
Sparavohn, Chairwoman of the California Association of Midwives. I
will continue to represent members of the California College of
Midwives and be available to consult, especially in regard to
professionalism of licensed midwives, quality of care issues and the
appropriate standards of care for community-based midwifery practice.

I want to thank all the members of the Board and the staff for their
kindness and help through out the many years. I know it hasn't been
easy for any of us and I particularly appreciate the many times they
went the extra mile on behalf of California Licensed Midwives. Strange
as it may seem, I will actually miss you all and my regular attendance
at the quarterly Board meeting.

I attended my first Medical Board meeting May 3rd, 1993. In the
following 11 years I have been present at two to four meetings each
year and attended all seven of the midwifery licensing implementation
committee meetings held in 1994. For me, the last decade has been a
crash course in administrative law, the medical justice system, the
history of midwifery legislation in California and learning about the
physician and lay appointees to the Board and the hard-working and
dedicated people employed as the MBC staff. I made many important
friendships that I will always treasure. I particularly enjoyed being
a useful source of information about the physiological management of
normal birth, the safety of community-based midwifery and the risks of
medicalizing maternity care for healthy women with normal pregnancies.

Unfortunately, the history and circumstances that preceded my
political activism on behalf of LMs is not such an uplifting story.
From 1981 to 1991 I practiced midwifery lawfully, peacefully and
without incident as a Mennonite midwife under the religious exemptions
clause. Without any precipitating consumer complaint or bad outcome,
two agents of the Medical Board came to my home on August 9th, 1991
and served me with a criminal warrant charging me with five
misdemeanors. I was immediately arrested and handcuffed in presence of
my youngest daughter and transport to the Santa Clara county jail,
where I was held in solitary confinement for 13 hours until members of
my community could raise $50,000 bail. It's noteworthy that in 1991
the boxer Mike Tyson had just been arrested and charged with felony
rape. His bail for a felony rape charge was $30,000. The misdemeanor
charges against me required that my community to pay out $5,000 cash
to a bail bondsman. As you know, bail money is a non-refundable fee.

According to a radio news report attributed to the Associated Press,
the San Mateo office of the Medical Board stated that I was arrested
as a test case in regard to the religious exemptions clause. They were
hoping my prosecution would establish a precedent eliminating the
traditional practice of non-medical midwifery under the religious
exemptions clause. This incident occurred under the direction of Ken
Wagstaff, the executive director of the MBC at the time.

After 20 months of pre-trial hearing (and $30,000 of legal expenses),
the DA admitted that the non-medical practice of midwifery was
statutorily neutral, i.e., it was not a crime. He told my lawyer and
me that he was aware of the lack of statutory basis for criminalizing
traditional midwifery and said:

"I called those guys at the Medical Board and I told them that if they
wanted me to keep prosecuting midwives, they were going to have to get
some new legislation passed."

Within a few weeks of this conversation, the criminal prosecution
against me was mysteriously dropped (in its 21st month!) and the
legality of my practice under the religious exemptions clause was
formally acknowledged in the same court documents that dismissed the
charges against me. I attended my first Medical Board meeting in
Sacramento five days later (May 3, 1993), which was how I discovered
that public participation in the public meetings of the agency was
virtually non-existent, a fact that I interpreted to mean that crucial
element of democratic process – in this case public oversight -- was
functionally absent.

Since the mission of the Board is public/consumer safety, I considered
this lack of public participation to result in a patronizing and
paternalistic process that was just plain poor public policy. This was
the major motive in the many written requests by me for the quarterly
board meetings to be video broadcast over the Capital's cable system,
so that citizens all over our great big state could remain informed
and informing.

It also explained a lot about how the agency, under Mr. Wagstaff's
command in 1991, could have used its authority in such an
irresponsible manner. In targeting me as a member of a class for the
purposes of a `test case', the agency misappropriated the considerable
powers of California state government to carry out the long-standing
agenda of organized medicine to eliminate all forms of health care by
non-physician care providers. I guess I'm just old-fashioned enough to
believe that our state government shouldn't be used to carry water for
organized medicine.

Shortly after the criminal charges against me were dropped, the CMA
approached Senator Killea with a deal – if she would let them gut the
pending midwifery legislation authored by her in cooperation with the
midwives and permit it to be replaced by a licensing statute identical
to nurse-midwifery (complete with the same poison pill of mandatory
physician supervision), the CMA would guarantee its passage. During
one of the Assembly hearing on SB 350, Senator Killea explained to me
that: "Bad legislation is better than no legislation at all".

With this collection of precipitating events, the LMPA of 1993 was
passed and the same Medical Board that was responsible for the arrest
and criminal prosecution of midwives was now identified as the
regulatory body for midwives like myself. In a nutshell, that is the
story of how I came to be traumatically bonded to the Medical Board.
"Those guys at the Medical Board" may just be stuck with me for life,
as I am a firm believer that the democratic process is a necessary
ingredient in any effort to `protect' the public.

In light of these disturbing experiences and my inauspicious entry in
the medical justice system, followed by eleven years of representing
LMs to the Board, I believe that I have earned the right to offer some
observations on the topic of midwifery and the relationship between
the Medical Board, professional midwives and the obstetrical
profession. At 61 years of age, I am old enough to have seen profound
social changes, both in how medicine is practiced and in other topics
relative to social justice. I believe in working for social justice. I
am fundamentally optimistic that in my life time I will see the end of
the prejudice against midwives.

Background Remarks

But before I get to specific remarks about midwifery licensing, I'd
like to tell you two short but informative stories about my early life
in a deeply segregated society. As a teenager, my Canadian Mennonite
family moved to Florida in 1957 and for the first time in my life, I
was exposed to and shocked by blatant and institutionalized racial
prejudice.

I attended segregated public schools, I trained as a nurse in a
segregated hospital and I eventually provided maternity care in the
same segregated institution. Living up close and personal with
institutionalized prejudice and government sanctioned segregation I
had two very instructive experiences that I want to share with you.

The first story is about the public restrooms at a local gas station.
Instead of the usual arrangement of two restrooms, one for each
gender, the Bay station had three bathrooms. Big signs on each of the
three doors proclaimed either `White Ladies', `White Gentleman' or
simply `Colored'. Today we all can see this violation of common
decency as emblematic of a morally-bankrupt system that was
dehumanizing and wrong. It needed to be changed and eventually it was.
Wonder of wonder, I personally lived long enough to see
institutionalized segregation in the South come to an end. I believe
this to be an example that right does win out if one is willing to
work for it and wait for the process to come to fruition.

I had a second remarkable and life-changing experience as a nursing
student and a staff nurse working in the labor and delivery room of
that same racially segregated hospital in the 1960s. Due to its system
of medical apartheid, I got to closely observe and directly
participate in two entirely different systems, side by side, in the
same hospital, at the same time, with the same staff and the same type
of patients but totally different management style and outcomes,
different as day and night.

It was a naturally-occurring, one-of-a-kind scientific study
contrasting two styles of maternity care – a profoundly
interventionist model characterized as "knock'em out, drag'em out"
obstetrics, versus a lazier-fair system that resulted in, ipso facto,
physiologically-managed maternity care. It all depended on whether the
mother was black or white.

In our segregated hospital, Caucasian mothers were sent to the
all-white labor ward on Five-North. On admission they were immediately
given 3 grams of barbiturates (a double dose of sleeping pills). As
labor progressed they were injected every 2-3 hours with a narcotic
mixture known as "twilight sleep" – large and frequently repeated
doses of Demerol, tranquilizers and scopolamine, an hallucinogenic
drug that also caused short-term memory loss and profound amnesia.

Under the influence of these powerful drugs some women became
temporarily psychotic and physically fought with the staff and even
bit the nurses. Left unattended, they fell out of bed, chipped teeth
or broke their arms. To keep drugged women from getting hurt, the
hospital required a nurse to stay right at the bedside through out the
entire labor. However, we often delivered 8 to12 patients a shift.
When the nurses were busy, our white mothers were put in four-point
leather restraints, the same ones used in the locked psychiatric wards
of the hospital. This forced women to labor spread-eagle and flat on
their back, a position that interferes with and reduces blood flow to
the uterus and placenta, making labor extremely painful and often
causing fetal distress.

When time came to give birth, these mothers were moved by stretcher to
the Delivery Room, given general anesthesia, put in lithotomy
stirrups, a "generous" episiotomy was performed, and the baby was
extracted via `low' forceps. One of my jobs as a nurse in the
all-white Five-North delivery room was to resuscitate these deeply
narcotized and respiratorily-depressed babies. Out of every 25 babies,
one or more would fail to establish respirations, thus dying as a
result of the drugs, general anesthesia and/ or the use of obstetrical
instruments.

This high mortality rate was iatrogenic in origin, but that has never
been recognized or acknowledged by the obstetrical profession. And
yet, this high perinatal mortality rate is still within living memory.
For older physicians, these memories add to the mythology that normal
birth is intrinsically dangerous and requires many medical
interventions and by inference, that non-institutional midwifery must
be dangerous.

After the baby was delivered, the obstetrician inserted his hand up
into the mother's uterus to pull out the placenta. Then the episiotomy
incision was sutured, with particular attention paid to the so-called
"husband stitch", which was to make things tight for woman's husband.
As an 18 y/o student nurse, I was appalled. It should be noted that
the third leading cause of maternal mortality in the 1950 and early
1960s was anesthesia-related deaths.

Then as a student nurse I was rotated off Five North to One South, the
black ward in the basement of the hospital. Oddly enough, the
maternity care for black mothers was remarkably simple,
straightforward, non-interventive, and in my humble 18 y/o opinion,
infinitely more humane. It was also psychologically-sound and made
right use of gravity. As judged by the number of newborns who did NOT
need resuscitation at birth, it was vastly more successful than the
highly medicalized care visited on their Caucasian counterparts
upstairs on Five North. Frankly, this was all a big relief to me, as I
no longer felt that I was being asked to be an agent for a process
that was clearly and immediately harmful to mothers and babies.

On One South, there was no labor ward or labor room nurse to care for
black mothers. These laboring women were just admitted to their
postpartum beds in an old-fashioned four-bed ward. Their labors were
not accelerated with Pitocin or any other drugs. Neither were they
given medications for pain because the two staff nurses, who were
responsible for 40-plus other patients, had no time to labor-sit with
drugged and combative women having hallucinations. Besides, in a
segregated society, no one much bothered about the labor pain of black
mothers, who were assumed to either be tough and able to take it or
just out of luck.

However, there were many unintended advantages to this system of
purposeful neglect. Because they were unmedicated, our black women in
labor were permitted to walk around freely and socialize with the many
other experienced women on the ward. This was very comforting to them
and provided a useful source of encouragement and tips on how to cope
with an unmedicated labor. In particular, our black mothers avoided
lying in the bed, preferring to stand and sway or squat during
contractions while holding on to the bar at the foot of the bed. When
I, a green student nurse, asked why they didn't just get in the bed
and lie down, they looked at me like I must be really dumb and
answered in an irritated voice: "Because it hurts too bad when you lay
down". How right they were!

Eventually one of our maternity patients would start to make those
unmistakable pushing sounds and so we nurses grabbed a stretcher,
threw a sheet over the laboring woman and made a mad dash for the
elevator, hoping to get up to the delivery room on Five North before
the baby was born. However, so many mothers were high parity that we
routinely did not make it. I got my first experience as a "midwife" by
receiving the spontaneously born babies of black mothers who delivered
on the stretcher in the elevator half way between One South and Five
North.

The ease and simplicity of these nurse-managed, non-medicalized births
was in stark contrast to the invasive methods used by obstetricians on
our Caucasian patients on 5 floors above. As nurses talked these black
mothers through the last couple of pushes in the stalled elevator,
their babies just slipped out, with little fuss.

And wonder of wonder, these spontaneously-born breathed on their own,
since their mothers had not been medicated or anesthetized and no
artificial, forcible or mechanical means were used to force the labor
or extract the baby. There was no painful episiotomy, no river of
blood issuing forth from a gapping perineal wound, no forceps, no
fundal pressure, no bulb syringe jammed repeatedly down the baby's
throat, no manual removal of the placenta, no stitches, no
post-anesthesia vomiting, no artificial separation of mother and new
baby. Clearly Mother Nature, when respectfully supported and
un-meddled with, does a darn fine job.

By today's legal standards these black mothers were actually receiving
"substandard" care. Racial prejudice and discrimination of the era had
institutionalized the negligent treatment of them and their unborn or
newborn babies. Yet, they clearly were getting the better end of the
deal, as black mothers were not made to suffer the routine indignities
and painful interventions in their labor that were the inevitable lot
of while women.

The black mothers on One South got safer, physiologically managed
labors and normal spontaneous births. As a result, they were not
subjected to the labor-retarding effects of social isolation, to being
immobilization on their backs with four-point psychiatric restraints,
to the maternal effects of being profoundly narcotized or to the
slowly healing episiotomy that made it hard to sit and difficult to
care for a new baby. Their babies were not exposed to intrauterine
narcotics and resulting fetal distress and did not need to be
resuscitated, thus contributing to increased IQ points.

When expecting my first baby I took a lesson in childbirth out of that
same book. In an attempt to avoid the detrimental effects of these
interventions, I asked my obstetrician if I could have the same kind
of care that our black mothers received. He smiled and suggested that
I just stay out of the hospital until the baby was ready to be born
because "that's what hospitals are for -- drugs and anesthesia". So I
labored at home as long as possible, hoping against hope to have a
nice nurse-managed birth on a stretcher in the same elevator on the
way up to the Five North delivery room. As luck would have it, I
misjudged by just a few minutes. While my husband drove the car, I
gave birth alone in the back seat of our Renault, five blocks before
we got to hospital. That was the second major area of my experience in
midwifery.

Modern Times, Modern Problems

For the last 100 years the obstetrical profession in the United States
has gone to great lengths to convince all of us that physiological
management is old-fashioned, inadequate and down-right dangerous. They
have purposefully dismantled the infrastructure for providing
physiological management, claiming that care for normal childbirth, at
least for the affluent and the Caucasian, should consist of a constant
stream of medical and surgical interventions provided by physician-
surgeons in an acute care hospital setting. When it comes to the
astronomical expense of the interventionist model (particularly the
maternal choice or `elective' Cesarean), the sky's the limit, because
we are repeatedly assured that this extravagance is ** buying us
better babies**.

This is the origin of the conflict we are experiencing today between
independent midwifery and organized medicine. Organized medicine seeks
to shoot the messenger, as midwives are messengers for normal birth
and physiological management. Representatives of A_COG have appeared
before the Board many times, trying to convince you that licensed
midwives are dangerous because we do not medicalized normal birth with
the routine use of drugs and surgical procedures as they do.

At present, A_COG has identified a troubling example of biased
obstetrical research and media sensationalism as the centerpiece of
its objections to midwifery. A_COG would like Board members to think
that this study – "Outcomes of Planned Home Birth in Washington State"
-- is a comprehensive form of research that defines the scientific
literature on the risks of home-based midwifery care. They insist it
stands head and shoulders above all previous research, negates all
previous findings and is able to determine, once and for all, that
planning a home birth is fundamentally dangerous, end of conversation.

Unfortunately, this example of junk science violated virtually every
principle of good science in its design, its collection and
interpretation of the data, the reporting of its conclusions and its
ethical relationship to the scientific community and the public. (A
brief critique of this study is enclosed.)

However, we all know that if the physiological management of normal
labor and birth by professional midwives in non-medical setting
actually represented the kind of danger that A_COG repeatedly claims,
they would have gone to court ten years ago to obtain an injunction
against the implementation of the LMPA and practicing of LMs. A_COG
didn't do that because they can't do that.

While these unsubstantiated and self-serving claims may fool the lay
public, they do not standup under the rules of evidence in a court of
law. A consensus of the scientific literature not only supports
physiological management in all settings for healthy women, including
both home and hospitals, but the scientific literature also comes to
the conclusion is that in general physiologically-managed care is
actually safer and more cost effective for healthy women than
obstetrical intervention. It is the type of maternity care used
world-wide. It provides superior maternal-infant outcomes as compared
with the United States, with far less expenditure of money and finite
medical resources.

Historically the obstetrical profession does not have a good track
record at changing its practice as scientific evidence demonstrates
that customary treatments are ineffective or harmful. In spite of
scientific evidence supporting physiological management as the
standard for healthy women, organized medicine tries to justify the
medicalization of all normal labors, while it perpetuates its bias
against science-based maternity care and its prejudices against
midwives. In its own way, it is an institutionalized system of
apartheid in which mothers and midwives who employ physiological
management are discriminated against. Access to obstetrical services
is blocked and when those services become a medical necessity, both
midwives and mothers are often the victims of retaliation by angry and
outraged obstetricians, who themselves do outrageous things with
social impunity.

Before the passage of midwifery licensing laws, the strategy of
organized medicine was a sudden-death playoff that used criminal
arrest and the prosecution to achieve its goals. Since the passage of
the LMPA, the strategy to eliminate professional midwifery is 'death
by a thousand razor cuts', as organized medicine fights the practice
of licensed community midwives at every turn, with every dirty trick
and with just as much enthusiasm as before. If A_COG were to wear a
campaign button in their war against independent midwifery, they would
take their slogan from Bull Conner – the infamous, segregationist
sheriff of Birmingham, Alabama - who wore a button that said "NEVER".

The medical profession has always had an extremely contentious
relationship with any scientific discover or theory that threatened
established doctrines or practices. Notorious examples are the
rejection of the stethoscope, the germ theory and accurate
understanding of the circulation of blood. Bitter controversies
between doctors and other scientists that went on for many decades and
many ruined careers preceded the grudging acceptance and eventual
widespread use of these discoveries.

More modern example of unscientific and harmful practices includes the
routine prescribing of estrogens for pregnant women in the 1950s,
which resulted in vaginal and penile cancer in DES adolescents. Even
more recent and wide-spread was the routine prescribing of estrogen
for post-menopausal women, based on the unproven theory that this drug
would protect against heart disease and cancer when, in fact, it
increased the rate and severity of the very diseases it was supposed
to prevent. Recent examples that include the same kind of ridicule and
vigorous rejection of new theories as suffered by Dr. Semmelweis over
a hundred years ago was also visited on Dr. Heimlich, the physician
who developed the Heimlich maneuver and the Australian doctor who
discovered that the Helicobacter pylori bacteria caused stomach ulcers.

I predict that in time midwifery and physiological management will
also be 'discovered' and embraced by modern medicine and accorded its
proper place in maternity care for healthy women.

The History of Obstetrics

However, it is the obstetrical profession that had and continues to
have the most abysmal track record whenever scientific evidence shows
their customary practices to be ineffective or harmful. The historical
record shows that time and again the obstetrical profession has
resisted and rejected scientific knowledge if it refuted their
favorite theories or required a change of practices. The most
disturbing and well-documented display of this regrettable trait comes
from the 19th century story of Dr. Philip Semmelweis, who was a
professor of obstetrics at a prestigious teaching hospital in Vienna
during the 1840s. Dr Semmelweis amassed incontrovertible proof that
purulent organic material carried under the fingernails of doctors and
med students caused the fatal puerperal sepsis commonly known as
`childbed fever', which caused the death so many newly delivered
women. In his own words Dr Semmelweis concluded that: "puerperal fever
is caused by the examining physician himself, by the manual
introduction of cadaveric particles into bruised genitalia"

Unfortunately the obstetricians of Dr. Semmelweis' day, like Bull
Conner, also said "never", only this time it was to the idea that
childbed fever (or any other complication) could possibly be caused by
poor obstetrical practices. The specific practice in question was
doing vaginal exams on healthy laboring women without having washed
their hands between the autopsy room and the labor ward. As a result
of this dangerous practice undelivered mothers became contaminated
with the haemolytic streptococcal bacteria carried from the corpses of
women who had just died, resulting in a virulent septicemia in the
laboring women that caused her death within 72 hours.

During the 18th and 19th centuries ten to fifty percent of maternity
patients (both mother and baby) died in the teaching hospitals of
Europe from haemolytic septicemia. According to historical records,
the all-time worst epidemic of contagion occurred at the University of
Jena, when ** not a single mother left the hospital alive for four
years in a row**.

The "usual and customary" practice of obstetrics in the 19th century
included the post-mortem dissection of women who died from puerperal
sepsis. In this regard Dr Semmelweis and his colleagues were privy to
a lot of educational `opportunities'. In association with these
routine autopsies, cadavers were also used to demonstrate the
mechanics of obstetrics and permit students to perfect their use of
obstetrical instruments. Prior to this era, a biologically-safe
teaching manikin, developed by French midwife Madame Cordray, was used
to teach midwifery skills to student midwives and instrumental and
manipulative obstetrics to physicians and medical students. These
life-size teaching manikins each had an anatomically correct pelvis,
pregnant uterus occupied by a realistic fetal doll, fake amniotic
fluid, placenta and umbilical cord and access to uterine contents thru
a working genital tract.

As dissection became a more important part of medical school education
the obstetrical manikin fell out of favor all across Europe. Gradually
the bio-safe manikin was replaced by the bio-hazardous cadavers of
women who died in childbirth, with the assumption that such cadavers
were a "superior" teaching resource that would result in a superior
medical education. Each body to be used for teaching purposes was
amputated at the waist, the visceral organs removed from the abdominal
cavity and the uterus dissected out. This was to prepare the amputated
and hollowed out lower half of the body to receive a recently deceased
newborn, which was placed inside the pelvis for teaching purposes. By
passing a series of dead babies down thru the disarticulated pelvis of
a recently deceased woman, a professor of obstetrics could control the
learning experience and assist his medical students to could carry out
vaginal exams, determine fetal lie and position, apply obstetrical
forceps, practice fetal destructive operations and learn life-saving
maneuvers such as podalic version for obstructed births.

Podalic version was an invasive procedure in which the physician
reached up into the uterus to turn a vertex (head down) fetus into a
breech position, so that an otherwise undeliverable baby could be
pulled out by the feet. Before the development of anesthesia and
aseptic technique, which would pave the way for safe cesarean
sections, the only choices for an obstructed labor were between a
fetal destructive operation or delivering a live baby via podalic
version.

However, the acquisition of all these life-saving skills by medical
practitioners came at an awful price, as the use of cadavers for
teaching virtually guaranteed that highly-contaminated organic
material would be carried into the labor wards by doctors fresh from
the dissection lab. In some hospitals, as many as 700 new mothers (and
their babies) died each year, or approximately two a day. In Vienna,
nineteen hundred and eighty-six women died in Division One at the
University of Vienna hospital between 1841 and 1846. In Division Two,
the midwifery program staffed by graduate and student midwives, the
mortality rate was only 1/5th of that in Division One during the same
period of time.

It is important to note then (as now) that many knowledgeable people
were critical of the prevailing obstetrical practices. This included
other physicians and midwives who were all unwilling to settle for
superstitious explanations that blamed these fatal epidemics on
everyone and everything else other than suspect obstetrical practices.
The director of obstetrics in Semmelweis' time had a fantastic list of
39 incredible explanations for maternal deaths, such as miasma (bad
air), chilling, `milk' fever, errors in diet, maternal emotions that
suppressed the flow of the lochia and the `unstable' condition of
women. What they all had in common was that each supposed cause was
indefinable, untreatable and/or unpreventable and so they completely
absolved physicians of any culpability or even the need to search for
a cause or a cure. On the contrary, obstetricians got to portray
themselves as heroes, saving women from viciously defective
reproductive biology, no doubt a lingering effect of God's curse on Eve.

Over the course of the previous century a small but substantial number
of astute physicians all over the world – Doctors White in England,
Gordon in Scotland, Cederskjšld in Sweden and our own Oliver Wendell
Holmes in Boston -- had all observed, studied and warned of the
iatrogenic nature of childbed fever. Part of the evidence was that the
repeated virulent epidemics of puerperal fever were virtually absent
in places that midwives (who did not use instruments) managed normal
birth instead of doctors (who did) and where autopsies were not being
done by the same practitioners who attended deliveries.

An article by Oliver Wendell Holmes appeared in the New England
Journal of Medicine and Surgery in 1843, entitled `The Contagiousness
of Puerperal Fever'. In this he agreed with Doctors White and Gordon
that the disease was often transmitted, via an unknown agent, by both
physicians and nurses. Unfortunately, these `radical' life-saving
ideas were ridiculed and dismissed as absurd by those who thought it
inconceivable that the healing hands a physician (or his instruments)
could ever, under any circumstances, be a vector for a contagious
fatal illness.

History records that Dr. Phillip Semmelweis reformed these iatrogenic
practices by introducing prophylactic hand washing in a chlorine of
lime solution. Like a sudden overnight miracle, maternal deaths in
his institution fell from 18.27% to 0.19% in the eight months between
April and December of 1847. As a result he devoted his entire career
to preventing unnecessary maternal deaths by teaching and preaching
the use of asepsis principles.

None-the-less Dr. Semmelweis' simple but effective solution was
ignored and ridiculed by his contemporaries, who could not wrap their
minds around something so unglamorous and straightforward, something
that would have required them to take responsibility for harmful
practices and most important of all, make necessary changes. For his
trouble he soon lost his prestigious post in Vienna's most famous
hospital, lost his reputation and eventually his profession. As they
say "No good deed goes unpunished". In the end Dr Semmelweis was
driven mad by guilt and his inability to "make them listen". At the
age of 47, a mere 21 years after receiving his medical degree, he died
in an insane asylum, leaving behind a wife and several children.

The medical profession did not finally acknowledge the role of
contagion until 1881, when a French physician, the now famous Dr.
Louis Pasterur, established the central role of microbes -- commonly
known as `germs' or `pathogens'-- in causing illness and infection. On
a chalk board at a prestigious medical meeting Dr. Pasteur drew a
graphic representation of what the streptococcus bacteria looked like
under a microscope -- rectangular microbes that resembled a string of
box cars on a train track -- and said "Gentlemen, this is the cause of
Childbed Fever". With this discovery, Dr. Pasteur delivered the fatal
blow to the erroneous and dangerous doctrine of `spontaneous
generation' -- the theory held for 2000 years that life (and
infection) could arise spontaneously in organic materials.

The idea of surgical `sterility' as we know it today is little more
than a 100 years old. Before this time the use of invasive techniques
and instruments were extremely dangerous and correctly seen by the
public as methods of "last resort". It was not until the discovery of
anesthesia in the 1840s to control the inevitable pain of surgery and
40 years later, the germ theory of disease and use of sterile
technique to prevent the infection that surgery became a reasonably
effective form of medical treatment. The first-ever obstetrical
operation -- a Cesarean -- was done in first century Rome to extract a
living child from its dead or dying mother. Anesthesia made it
possible to do Cesareans on living women and sterile technique made it
possible for living women to survive the operation. Episiotomy,
forceps and other invasive procedures were also greatly enhanced by
the use of anesthesia and sterile technique. Obstetricians had such
enthusiasm for these new technologies that it didn't take long for
operative obstetrics to become the "wave of the future". By 1910,
operative deliveries in one famous NYC hospital were already up to 20%
of all deliveries or one out of five births.

It would be lovely to report that the obstetrical profession learned a
valuable lesson from the regrettable era of Dr. Semmelweis. I'd like
to report that the profession had developed the habit of
evidence-based practice – scientific inquiry, listening respectfully
divergent opinions, taking feedback to heart and putting in
corrections as necessary. However, scientific studies evaluating the
mortality rate of obstetrical care after the obstetrical profession
eliminated the practice of midwifery (approximately 1910 to 1930)
showed just the opposite.

Instead of the vast improvement they promised, there was a 15% annual
increase in maternal deaths for more than a decade and a 44% increase
in neonatal birth injuries over the same period. The escalating rate
of mortality and morbidity was the direct result of replacing the
safer, physiologically-based care of healthy women as provided by
midwives by routine use of obstetrical interventions including general
anesthesia, episiotomy, forceps and manual removal of the placenta.

This highly invasive style of obstetrical care was still in vogue in
the 1960s and early 70s when I was a nursing student and L&D nurse.
The connection between the history of obstetrics and the issues of
`modern' obstetrics are not as remote as most people might imagine.
The reason is the 20th century style of operative obstetrics was
actually developed was as a correction for the iatrogenic contagion
and preventable deaths associated with obstetrical care.

After more than a hundred years of resistance, the obstetrical
profession finally acknowledged the contagious nature of puerperal
sepsis. Better yet, they embraced the `new scientific method' as hot,
sexy and vastly superior to the old days and old ways. Medical men (as
they preferred to be called at that time) had always had a hard time
distinguishing themselves from midwifery, which was seen as low class,
low pay `woman's work'. The use of obstetrical forceps and podalic
version were favorite methods to rise above the low status of
midwives, but these were also associated with fatal septicemias.
Aseptic and sterile techniques promised to end these problems.

The obstetrical profession assumed (wrongly it turns out), that if
labor and delivery were simply conducted under conditions of surgical
sterility, all would be well regardless of the number of invasive
procedures performed. They assumed that the scientific advances of
"modern" medicine would now permit obstetricians to take control of
normal childbirth in a way they dared not do before. By conducting
normal childbirth as a surgical procedure, they could routinely
mechanize it thru the use of anesthetics, episiotomy, forceps and
manual removal of the placenta. With this kind of complete control
over normal (otherwise unpredictable) biology, they could dramatically
speedup the process. Obstetricians theorized that a faster, more
controlled process would be better for mothers, babies. And of course
that same control and greater speed was more conservative of the
doctor's time, more profitable for the hospital and all around better
for everybody. Entirely left out of this picture were the principles
of physiological management, which had been happily discarded as
irrelevant.

A century earlier, the power brokers of the medical world all turned
their backs on any evidence or suggestion that their practices caused
or contributed to maternal deaths from sepsis. For the next hundred
years, a new generation of obstetricians has turned their backs on
physiological process and rejected the principles of physiologic
management. Today, the routine interference in normal pregnancy and
birth is the hallmark of contemporary obstetrics, in spite of the fact
that this `style' is also illogical, unscientific and harmful. In 1989
Dr. Iain Chalmers, the Oxford University researcher who published the
first comprehensive review of evidence-based obstetrical practice (The
Guide to Effective Care in Pregnancy and Childbirth), bestowed the
"Wooden Spoon Award" on American obstetricians, with the disdainful
comment that of all the branches of medicine, our obstetrical
practices were the least scientific.

Like the movie Ground Hog Day or the folk song about the man trapped
on the MTA (Massachusetts Transit Authority), contemporary obstetrics
has trapped us in a vicious cycle that currently prostitutes the
historical ideals of medical care – "in the first place, do no harm".
The issue is A_COG's relationship with credible science and whether
A_COG cherry picks its research based on the organization's hidden
agenda. As in Semmelweis' day, modern-day powerbrokers continue to
ignore scientific knowledge that is inconvenient, unprofitable,
refutes a favorite theory or requires a change of practice. It happily
uses junk science in an attempt to discredit physiological management
while providing obstetricians with a free pass to employ ever
increasing and ever more extreme interventions, including the now
popular "maternal choice" cesarean.

Solutions – Win-Win for everybody

I am here to testify to two things – Bull Conner was wrong about
segregation and so is the obstetrical profession when it comes its
prejudice against physiological management and the medical apartheid
of midwives. A long over-due and much needed reform of our national
maternity care policy will eventually bring an end to Flat Earth
Obstetrics. For the first time in modern times, maternity care for all
healthy women will be science-based and mother-friendly, which to say,
it will integrate physiological principles with the best advances in
obstetrical medicine to create a single, evidence-based standard for
all healthy women.

When that happens, physiological management will be the foremost
standard for all healthy women with normal pregnancies, taught to and
used by all practitioners (both physicians and midwives) and for all
birth settings (home, hospital, birth center). Then the so-called
'midwife problem' will resolve itself **on its own merits**.

My question for the members of this august body is simply this: "When
history records the story of this triumph of reason over prejudice,
which side will you be listed on? Will you know in your own hearts
that you did what you could advance both science and social justice?
Will your relatives in future generations proudly count you as a
patriot for rights of healthy childbearing women to receive safe, cost
effective and science-based maternity care?

Today is September 11th, 2004. On that extraordinary day 3 years ago,
a lot of ordinary people became heroes because they were brave enough
to go up the down staircases in the Twin Towers to help people in
need, irrespective of the obvious risk to themselves. Hundred of these
ordinary heroes died as a result of their courage and commitment.
Mother and midwives are not asking anyone to sacrifice life, limb or
livelihood for our cause. We are however asking for members of the
Board to go up the down staircase of medical politics. We are asking
each of you to go the extra mile, to make your decisions based only on
the consensus of the scientific eviden