Wednesday, June 12, 2013

Women's Rights, Alabama Law and Midwives

For the last several years, an amazing group called the Alabama Birth Coalition has been working
Photo from SoulVegMama
tirelessly to bring about legislative change which will allow Certified Professional Midwives (CPM's) to practice in Alabama. This legislation is important because in many rural counties, women have to drive an hour or more to the nearest hospital with a maternity unit. Families who don't want medical community involvement may end up giving birth at home without any attendant at all. Legalizing CPM's and home birth would offer these women another option. Furthermore, creating legislation that sets forth licensing requirements and regulates the practice of CPM's actually helps to ensure that women choosing home birth receive a high standard of care.

The Opposition 

Opponents of the bill, however, are many and powerful. Unfortunately even within the midwife community, there is sharp disagreement about this legislation. Certified Nurse Midwives (CNM's) sometimes cite the lack of medical training received by CPM's as a reason not to support the bill. Are their concerns legitimate? Certainly the kind of training that CPM's receive is different in nature than that received by CNM's. It is definitely more focused on out-of-the-hospital births. In fact, a candidate cannot even become a CPM without experience in at least 10 births in a non-hospital setting.

While it is true that we do currently have 17 CNM's in the state of Alabama, only a very small handful of them are actually catching babies! Some work in doctor's offices, others teach, but only 3 or 4 hospitals in the state have a CNM delivering babies. Why is that?  Why isn't there a single freestanding birth center in this state? In one word, the answer is MONEY.  Blue Cross, Blue Shield of Alabama, the largest insurance provider in the state, doesn't reimburse for midwife delivery the way they do for a physician delivery...not even close! Plus, the Alabama law is written in such a way that a midwife may only practice under direct supervision of a physician. Essentially, her supervising doctor is supposed to be on the premises when a midwife is delivering. Few doctors are willing to have midwives deliver under those conditions.

The Reality

Dr. Pippa Abston 

Within the medical community here in Alabama, it is common to hear how unsafe home birth is. But is it really? Dr. Pippa Abston, a pediatrician and instructor in the UAB family residency program used to agree with those who opposed home birth. In fact, she was a rather outspoken opponent. However, she began to thoroughly examine this issue, to actually see what a CPM does, and to understand just how badly we need the quality of care in many Alabama communities that a CPM would provide. In fact, Dr. Abston wrote a 5 part series about the importance of CPM's for Alabama women. It will take some time, but if you really care about this issue, you need to read Dr. Abston's excellent series. She has covered everything from the training of  a CPM to the safety issue to the desperate need in our rural counties.

The Root Issue

    This is, at it's most fundamental point, a human rights issue. Last Friday evening The Alabama Birth Coalition sponsored a presentation of the film, Freedom For Birth. Take 15 minutes to watch the abbreviated web-version of this film. It details the cases of Hungarian midwife, Agnes Gereb and Hungarian mother, Anna Ternovsky. In 2010, The European Court of Human Rights affirmed that a woman has the right to give birth in the place and manner of her choosing.
    Hungarian midwife Agnes Gereb

    The United States Supreme Court in the infamous Roe v. Wade decision in 1973 stated that a woman has the right to abort her unborn baby - a decision I don't personally support. However, based on that precedent, it is utterly illogical to say that she doesn't have the right to choose how and where her baby (whom she has chosen not to kill) can be born.  Even in the highly unlikely event that Roe v. Wade were ever reversed, it should be a common-sense decision to view a woman's right to give birth as she pleases as her decision to make. Whether a physician or a competent midwife  performs her prenatal care should be up to her. If a mother has chosen the midwifery model of care, and her midwife realizes that something is amiss, then her midwife should be able to have a collaborative professional relationship with a physician and should be able to stay with the mother throughout  whatever kind of birth the mother needs at that point. Opponents may say that this endangers mothers and babies. However, in the Netherlands where this is the model, the maternal and infant death rate is lower than that of the United States.

    A Call to Action

    There are many states in this country where women have absolute freedom to give birth in the manner that is most comfortable for them.  Alabama, however, is definitely not one of those states. We would do well to look at the maternity care models in states like Texas, Tennessee,  and New York. Two separate and very important things need to happen legislatively in Alabama:
    Hungarian mother Anna Ternovsky
    1. CNM's need to be authorized by law to work without direct physician supervision in any birth setting, and insurance reimbursement for their services needs to be mandated.
    2. CPM's need to licensed and regulated by the state to ensure that mothers desiring their services are getting the highest possible standard of care. This will stop the mass exodus of birthing mothers to surrounding friendlier states, and allow mothers in the poorest Alabama counties access to local well-trained professional birth support.
    Anna Ternovsky was willing to take her fight to the highest court that held jurisdiction over her country.  Will it actually take a mother here beginning that judicial fight to create the changes that must occur? I would hope that our legislators, midwives and physicians will find a way to come together in respectful support of mothers and babies before that happens. However, the Alabama Birth Coalition has been struggling for twelve years to bring about legislative change. Maybe now is the time to seek the kind of judicial ruling that will ensure all mothers have their basic right to give birth as they choose protected.

    Someday I would love to see a Free-standing birthing center here in Huntsville where both CNM's and CPM's work together and have healthy collaborative relationships with local physicians. There is absolutely no valid reason why this can't happen. And I believe it will. If all those who are concerned about birth in this state would simply work together, we could lower our infant mortality rate, provide high-quality care to the poorest among us, and make certain that every Alabama mother receives her basic human right to the birth of her choosing.


    1. Beautifully stated, Glenni! Thank you.

    2. Excellent! But doesn't CPM stand for Certified Professional Midwife? Although allowing CPM's to practice certainly would be practical! :) I hope more mom's and mom's-to-be join the ABC to affect change. You mentioned the Netherlands but the US is actually behind 33 countries in terms of maternal mortality. 33! And guess what! Most if not ALL of those countries employ and utilize midwives.

      1. Anna, you are absolutely right...changing it right now! Thanks so much for pointing that out!!!!!!

        We are doing a series on birth in the countries with the LOWEST infant and maternal mortality rates in the world!

    3. Thank you! But isn't the CPM credential much more encompassing than attendance at 10 births?

      You said, "In fact, a candidate cannot even become a CPM without experience in at least 10 births in a non-hospital setting." Actually, a candidate to sit the NARM exam must have an education that is generally equivalent to a master's degree from a certified institution, or attendance with increasing responsibility at many, many births. In fact, a candidate for the CPM credential often has demonstrated expertise in a wide variety of skills at hundreds of births, and spent thousands of hours practicing the midwifery model of care under supervision. Then the NARM exam is an intense written examination of a candidate's knowledge. It's not an easy credential to gain at all.

      1. I can certainly see how that comment was misleading. Thank you so much for your clarification!

        My intent was to point out that in order to even become a CPM, a candidate MUST have home birth experience (which is not the case for the CNM credential). I know that not everyone who reads the blog will click on the link to the training that a CPM must have, so I really appreciate your taking the time to elaborate on it.

    4. Thank you Glenni for this amazing blog post. I appreciate your support of midwives. ~Tori Dennis, RN, CPM~

      1. Thank you for what YOU do, Tori! You're giving women another very important option!