Thursday, September 29, 2011

Carla and how she won the arguement

This was a writing assignment for my arguementative writing class. The essay was about arguement history and how I may have thought one way and changed my mind after listening to a different point of view.

I used to think that holding a license to practice a skill, such as herbal medicine, acupuncture or midwifery was the right thing to do in order to ensure the safety of the public. It seemed that this form of regulation could make sure that those people providing these services were held to a certain standard, had to have a reasonable amount of qualified education and that someone was looking over their shoulder to make sure they were doing the right thing. I figured this would protect the public and the practitioner alike.

I even held a license as a massage therapist. After 600 hours at school learning the very basics of anatomy and physiology, bare minimum techniques, paying a few hundred dollars and completing a state test, I was set out to the public to practice massage in a variety of settings from chiropractic offices to five star hotels and spas. I thought I knew it all. Then I realized there was a lot I didn’t know and that the schooling had not prepared me for the real job and the variety of issues I would encounter in the people who lay on my table. In fact I was less qualified out of 6 months in school than I would have been had I learned from an apprenticeship in an office that dealt with the kinds of ailments I wanted to specialize in. And I sure had no clue how short lived my career as a Licensed Massage therapist would be or how hard I would have to work to earn a living or the types of obscenities I would have to deal with because of misconceptions about the scope of practice of a professional massage therapist.

Now I am pursuing a career in midwifery. Most people view midwifery as much more encompassing of a medical profession than massage therapy is, and certainly there is more contact with bodily fluids and some bigger risks involved, but to be honest, it is not too much different. But the common perception is that anyone helping pregnant women deliver their babies should have at the very least a nursing degree and many years of school. The requirements to legally practice midwifery are different state to state and in Oregon licensure is currently voluntary. Licensed midwives are required to pass a state exam after meeting some requirements including attending a minimum of 40 births and being capable of doing some clinical skills like blood draws, suturing, CPR and neonatal resuscitation. Dues are paid to the state and you become a member of a council. The board of directors that run the state regulatory entity are compromised of a few midwives, OBGYNs and public figures. ( note that there are no midwives on the OBGYN board of regulation) They determine the scope of practice and give midwives permission to use controlled substances (like medicines to stop hemorrhages) and carry oxygen. They also restrict the services of midwives to certain low risk clientele, as well as make the determination of who falls into that category.

I thought this was a perfectly reasonable way of regulating the safety of the public as well as making sure that midwives were practicing in a way that they couldn’t get themselves in trouble. I thought this was a great way for doctors to feel comfortable supporting midwives as a back up physician in the case that the midwives needed to refer a client to them or seek help in complicated situations. This system also allows for midwives to be paid through insurance companies, both private and state funded. What I didn’t realize was that the board of people who made the decisions on who can practice what on and what category a woman falls into (High/low risk) were not taking into account the most recent scientific data available that would allow for a broader range of practice. That is until I read a well spoken argument from the director of the school I am now attending to become a midwife. Carla Hartley is a long time educator of midwives and activist for rights of parents to choose how and where they birth and who attends their births. When I first encountered her and started reading the blogs she has posted about the subject of licensure in midwifery, I thought she was an extremist and she was out of her mind. I listened because part of me knew that what she said made sense, but I had no clue just how much until I started apprenticing with licensed midwives in the state.
During my apprenticeship, I watched one of my preceptors struggle with upholding her duty as a licensed provider and give the best possible service to her beloved moms. I watched as the boundaries the state put on her work were stretched as she consulted with physicians, researched, and served her clients who were also consulting, researching and doing everything they could to ensure the safe delivery of their baby. Under Oregon law, a licensed midwife has to refer her client to an OBGYN if the pregnancy exceeds 42 weeks. A mother who was on the cusp of being “high risk” due to her age had hit that mark in her pregnancy and labor was not coming on anytime soon. She had no other “risk” factors with the exception of one high blood pressure reading that resolved on its own and could have been caused by the stress of knowing that if she didn’t produce a baby in the next few days her plans of her dream home birth with her trusted midwife would be ruined by red tape. This mom and dad tried everything to self induce so they could legally have their chosen care provider perform the duties they hired her for, despite all the scientific research that said she was safe and could have patiently waited for her baby to arrive. I honestly believe that the pressure to perform and the inability to just relax and surrender to her body and baby prevented her from going into labor, like an animal being watched who just wants a private spot in safety to give birth to their baby. After a week of fighting and even refusing a scheduled cesarean, she finally surrendered to the pressure and submitted to a cesarean to birth a healthy, normal weight, baby girl.
Other restrictions that are deemed safe by the WHO and several colleges of OBs include extended labor and 2nd stage, VBACs (vaginal birth after cesarean section), and in some states multiples and breech presentations. For some parents, the idea of going to the hospital and risking episiotomies, major abdominal surgery, infection, and even death is too much and they prefer the comfort and familiarity of their home and family as support people. Restrictions that hospitals put on people and policies made to protect the hospital and staff can and do create many problems that they are supposed to prevent in low risk women. Home birth has risen 20% since 2004 due to these very factors. Licensing midwives in a way that prevents them from practicing their skills on a case by case basis is taking a choice away from mothers who deserve the right to choose what they and their babies are exposed to during birth. Statistics show again and again that planned home birth is as safe as a hospital birth and in some cases safer for low risk mothers. Many of the issues that have been presented as high risk or outside of normal are not as risky as these deciding boards have been making them out to be and these decisions seem to be more about filling the pockets of the doctors and hospitals than about the actual safety and concern of the mothers who want the choices.
I was absolutely blind to these circumstances until I read Carla’s take on it and then saw for myself how the one-size-fits-all laws restrict perfectly healthy, educated women from making decisions in their own best interest. My husband likes to argue that regulation of midwifery is necessary and if the problem seems to be the way in which we are regulated, than I should seek to change the implementation, not licensure, but I still think that licensure is the problem because our culture will never allow natural medicine, alternative therapies and non western medicine to be autonomous. There is too much money and power to gain in surgery and pharmaceuticals and if a cheaper, safer way of maintaining one’s health became widely accepted in our culture, they have too much to lose. I don’t see how this paradigm will be shifted until people start becoming educated about their choices and demanding to have access to them as well as holding themselves responsible for the choices they make. If people were encouraged to be responsible for their decisions, they couldn’t blame the doctor’s or midwives when something doesn’t go as planned, they would have to see how their choices effected their outcome and how they can do better next time around, if they are lucky enough to have a next time.


  1. If people were encouraged to be responsible for their decisions, they couldn’t blame the doctor’s or midwives when something doesn’t go as planned, they would have to see how their choices effected their outcome and how they can do better next time around, if they are lucky enough to have a next time.
    Thanks so much for sharing this with me. I am glad that I could be a part of your process toward becoming a woman/baby first advocate and midwife!

  2. Well written piece. So many great points as you take us through your journey from believing licensure was the way to go to seeing that it really is not in the best interest of many of the women that licensure is supposed to serve. I am posting this on "Birth Freedom Network" Facebook page. This fits so well with the purpose of the group. Thank you for writing this.