Tuesday, April 19, 2011

Women and The Challenge: Part 2

One of the presenters on Challenges to Midwives in South Dakota was Natalie Thiex.  Ms. Thiex is an epidemiologist with her MPH & PHD and presented an overview of birthing options in South Dakota.   was surprised to learn just how few hospitals there are in South Dakota that provide labor and delivery services, comprehensive obstetrics, and/or support Midwife attendance to pregnancies.  With a state that has fewer than 30 hospitals providing these services to our women and families, one would think that we would look at midwives attending births as a more serious option for the public of SD.

Ms. Thiex also mentioned that midwife attended births are supported by the American Public Health Association, and the World Health Organization.  Out of hospital providers supported by these two organizations would be Family Practice Physicians/Obstetricians who are in private practice, Certified Nurse Midwives and Certified Practical Midwives.  Here's a brief timeline of midwifery in South Dakota.

Other states both allow and have insurance help cover both CNM's (Certified Nurse Midwives), CPM's (Certified Practical Midwives), and CRN-NM (RN's also licensed in midwivery). There are currently 3 hospitals/birth centers in South Dakota that have CNM's, two of which are on reservations, which is both practical and focused on the woman and family's rights for their birthing choices.  Only 21 out of our states 66 counties have birth services of any kind.  In our country, only 12 states do not license CPM's.

Certified Practical Midwives or CPM's do 75% of out-of-hospital births in our country.  They usually will only take low risk pregnancies and birth and their scope of care is prenatal, labor & delivery, and post natal care. They use an educational model called The Midwife Practice Model.  It's very challenging.  Their education include academic coursework very similar to, if not the same as that of registered nurses with bachelors degrees and training in labor & obstetrics.  For clinical practice to  get this certification, they have to complete 1350 clinical hours and it takes anywhere from 3 to 5 years.  They take a clinical skills assessment and a written exam that has 350 questions and takes over 8 hours to complete.  Only after those are completed, can they gain their CPM license.

A modern midwife must have most, if not ALL of the same tools available to them to use during labor and delivery that most hospitals in South Dakota would offer in a labor and delivery room.  IV fluids, oxygen, neonatal resuscitation equipment, pharmaceuticals that can be used if labor stalls, pain assistance, anti nausea meds (usually Phenerol, Toradol, Pitocin, Phenergan, Zofran), and have the skills and tools available (hand held Doppler monitors, etc) to assess if the labor and birth has turned into an emergency situation that must go to the hospital for further assistance.

The epidemiological evidence for out-of-hospital births (low risk births evaluated) is consistent with that of low risk in-hospital births.  In a 2005 study of 5000 ooh births there were no maternal deaths and 1.7 per 1000 births that resulted in infant death.  It might be painted out that half of those deaths were SIDS related, and not birth related.  Only 12% of these o.o.h births were transferred because they become emergency situations.  About 5% of those births were normal, it was post birth complications such as a retained placenta that needed to be take care of surgically.

In 2008, the neonatal mortality rate, including high risk pregnancies for both out of hospital births and in hospital ones was 5 out of every 1000.  The main opposition to out of hospital births are medical and pharmaceutical lobbyists.  Part of this stems from the fact that most of o.o.h births require far fewer pharmaceuticals.  Using induction methods and pain killers is at a rate of 9.6% or less rather than 21% in hospital births.  These percentages were figured comparing South Dakota, New Mexico, and Minnesota- all 3 have similar population density and stratification.  The percentages also showed that in 2007, in these 3 states 32% of births were costly cesarean sections.

Overall, an out of hospital birth for a low risk pregnancy should be the consumers choice.  A lot of families who choose out of hospital births report being more satisfied with higher levels of individualized and in-depth prenatal care and counseling, and that they were also more satisfied with their post natal care for both the woman and child.

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