Graduation!

It’s midnight, May 27th. I just had a wonderful graduation dinner and party at my mom’s house. As of later on today, I will officially be a doctor. 

 Hooray, me!

Career day embarrassment

I am one week and three days from graduation. WOOOHOOOOOOOOO!

I am incredibly busy, which means I am also paralyzed in the face of all the crap I have to do, and procrastinating on the internet. Hello!

Yesterday I was a presenter for career day at my 7 yr old son’s school. I wore my white coat, wore scrubs, and brought my stethoscope and other tools. I presented in six classrooms (exhausting!), but started off in my own son’s first grade class.

I had an apron with sort of anatomically correct removable velcro body parts, which I used to play a matching game with the kids. If a kid guessed which organ I was describing (this organ is a muscle that pumps blood to the body!) then that kid got to put that organ on the volunteer kid who was the “body” wearing the apron. It was especially fun when we got to the kidneys and the large intestine. Poop! Pee! “EWWWWWWWW!”

There were only seven body parts, though, so I brought in my ragtag collection of toy doctor tools. Several people bought toy doctor sets for my kids when I got into medical school, so I had four plastic stethoscopes, a plastic syringe, toy otoscopes, etc. I passed those out to the kids who didn’t get to put on an organ, so thy could guess what they were used for, and was one kid short. So, I gave that kid my coffee mug. I made a joke about how that was the most important doctor’s tool, since it helps keep doctors awake, and remarked on how much coffee I drink.

My son rose his hand, and offered, “She drinks beer, too!”

I said “And, goooodnight everybody!” and quickly defended myself. “I didn’t drink any this morning! I didn’t have any last night!” and spent the rest of the half hour trying to convince my son’s teacher that I don’t have a drinking problem.

*facepalm*

Reply turned post, midwives are hacks style

When I signed onto Facebook this morning, a link showed up on my feed from a page that I don’t remember “liking”, but, as it is called “Nurtured Moms”, I can see it being a possibility.

The link was to an article by OB Management examining collaboration between ob/gyns, nurse midwives, and CPMs / lay midwives. The original article is actually not that bad, and does encourage collaboration with midwives (mostly with CNMs) and higher standards and licensing for CPMs, which I support. It didn’t accurately give the background on the Flexner Report, the purpose of which was to weed out inferior MEDICAL SCHOOLS, not midwives. But, I didn’t bring that up because I thought it wasn’t fully relevant to the discussion.

The posting on the Facebook page included the caption:

Exactly. In fact, it is even worse than the article suggests.

It states, “The North American Registry of Midwives’ Portfolio Evaluation Process requires midwives to be the primary care provider during 50 home births and to have 3 years’ experience. The average ObGyn resident gets this much experience in 1 month.”

However, this is not the requirement one needs to meet to become a CPM; this is the requirement to be a PRECEPTOR of CPMs — to pass your “knowledge” on to others!! In fact, to become a CPM, you only have to attend 20 births as a primary care provider. Also, just this year, they added the requirement for a high school diploma. For the last 15 years, you didn’t even need one to become a CPM. The most recent requirements are here: http://narm.org/req-updates/

The first commenter said this:

People need to understand that high standards do not limit choice for mothers. It boggles my mind when I hear lay midwifery apologists insist that making CNM the standard would “limit mothers’ choices.” Limit *what* choice, exactly? Oh right, clearly they want women to be able to “choose” substandard care (CPM) even though the very best (CNM and OBGYN) is readily available to everyone. It’s disgraceful that in America we allow uneducated hacks to practice medicine on the most vulnerable citizens. The ACOG is right not to “collaborate” with lay midwives.

I posted this:

The requirements for direct entry midwives are higher than that in Florida. Also, ob/gyn residents are already licensed doctors by the time they get that experience. There is no requirement for any specific clinical experiences first, although most medical students do at least observe a certain number of births.

Also, ob/gyn residents are not on labor & delivery every month. It depends on the training program, but most involve less than 100 vaginal deliveries a year.

Don’t get me wrong. I am a supporter of adequate training for CPMs/DEMs/LMs. I am also a supporter of accuracy.

Commenter #1 replied:

Accuracy? Lay midwives’ “education” pales in comparison to that of legitimate medical professionals. That’s accurate. Split all the hairs about med school that you like– lay midwives are still substandard, full stop.

I replied:

I am not splitting hairs. I am giving accurate information. A first year ob/gyn resident on her first labor and delivery rotation may have never caught a baby herself. She is a “legitimate” licensed medical professional.

Again, I am all for adequate training and licensing for CPMs. I do not think it is fair to call them all “hacks” or “substandard”. I also don’t think it is safe for ob/gyns or ACOG to not cooperate with lay midwives, nor is it accurate. ACOG does acknowledge that birth center births have been proven to be as safe as in hospital birth, and they support birth centers as a safe site of birth in their position statement, and most birth centers are run by CPMs or other types of lay midwives.

The best way to make homebirth and other out of hospital birth safe, other than adequate training of midwives, is to ensure seamless cooperation with other “legitimate” medical professionals when necessary. Anything less is unethical and unsafe for mothers.

Full stop.

I am not sure I am going to go back to comment on the thread, but if you follow the link to the new qualifications, 10 + 20 + 20 + 5 = 55 births required, not 20.

Awesome free resource!

I am so thrilled with the free books available at Herperian.org. They are designed for ease of use and medical accuracy, and take into account limited resources in remote locations. Each of the books is available in multiple languages.

I downloaded “Where There Is No Doctor”, “Where Women Have No Doctor”, and “Book for Midwives.” I haven’t had time to read them completely. Each one is more than 500 pages! I glanced through the midwifery book first, and was thrilled with what I saw. The section on the second stage of labor discourages frequent cervical checks, for example. It also has illustrations of alternative pushing positions, or in this case, physiologic pushing positions. The section on breastfeeding has accurate, non alarmist but very true information that formula can be harmful, including an illustration of an emaciated baby with diarrhea, warnings about unclean water sources, and the valid point that formula companies use predatory advertising practices to sell their product.

“Where Women Have No Doctor” has some overlap. There is a great section on abortion, with nonjudgmental language, and emphasis on safe abortion and management of complications. the chapter begins with reasons why some women choose abortion, and the first one is “She already has all the children she can care for.” Many people ignore the fact that most women who choose abortion are already mothers, and in developing countries with high maternal mortality rates, there is real danger to their already living children if their mother has an unwanted pregnancy. The midwifery book has a training chapter on manual vacuum aspiration.

Both books have good sections on family planning. Even though they are designed for practitioners in remote areas and perhaps minimal training, there is a good balance between necessary actions and not overstepping and perhaps causing harm by doing interventions with a lack of training. For example, the section on IUD insertion states that insertion can cause injury or infection, and should be inserted only by someone who is trained, but does not have alarmist contraindications. And, the book warns against putting in IUDs without permission, and the right to refuse an IUD.

The women’s health book also has a nonjudgmental section on sex workers, with information on risk reduction and negotiating condom use. It also has a section on women with disabilities.

I downloaded the Spanish version of the women’s health book. I figure I can read it to improve my medical Spanish, and I may be able to use it as a translation tool.

OK, I have gushed about the books enough. Go check them out!

Thanks, KK!

Reply turned post, blame the mom or the system? style

My buddy Jill of The Unnecesarean has launched an awesomely Rad Pitt (inside joke, you’d get it if you were from San Diego or South Beach) new project called CesareanRates.com. She shared a top ten list from my lovely state of Florida on Facebook, which got, as expected, an avalanche of disgusted responses.

It is hard not to see rates of 50, 60% + without choking on your third cup of coffee. OK, maybe I’m the only one on my third cup of coffee. And I didn’t really choke, since I was well aware that some hospitals down here have had rates higher than that, as you can see by Jill and my silly little guerrilla action here, which was when we first became partners in crime.

Well, in the flurry of comments on her Facebook page, many people followed the familiar line of – blame the moms. Blame the women for not educating themselves. Blame them for choosing a hospital birth over a homebirth. Blame them for being all Hispanic (Mexicans and Brazilians in particular were blamed for our cesarean woes) and wanting a cesarean. Blame them and the OBs for creating an atmosphere of fearing birth, and forget about changing that system, because it’s a lost cause. There are plenty of good replies to this, but I am sharing mine here:

OK, diving in. First of all, the Mexican and Brazilian population in Miami and Broward County is pretty low. Cubans are by far the majority of the Hispanic population. Also, research shows that maternal request and ethnicity as factors influencing primary cesarean are both way overblown.(1) In fact, some research indicates that being Hispanic decreases your chance of having a primary cesarean in the United States.(2)(3)

Training as an OB in residency and insurance are not the primary reasons why OBs in South Florida don’t want to do VBACs. My assertion is based on as yet unpublished research from my fellowship project. Residency sites are probably the most consistent place you can get a VBAC in Florida – note that someone on this thread is going to do a VBAC at Jackson, which is the only OB residency in South Florida. Most OBs cite malpractice concerns as their reason for not doing VBACs, and that was very consistent with responses in my research. And, no tort reform is not the answer, because Florida has had some of the most extensive tort reform for OBs in the whole US – OBs here can and often do “go bare”, which means they don’t even have to carry malpractice insurance, and can limit their liability totals in various ways. Jackson has immunity as a public hospital, also.

I have to say, I am not fond of blaming moms, either for their site choice or their cultural backgrounds. I also don’t think it is effective to turn our back on changing the system. As Jill said, almost all women choose to birth in hospitals. Even with out of hospital birth rates increasing, we are still talking rates around 5%. Of course, I have to believe on changing from within, or else my life’s path is a waste of time.

(1)http://www.childbirthconnection.org/article.asp?ck=10372
(2)http://www.ncbi.nlm.nih.gov/pubmed/19788975
(3)http://mchb.hrsa.gov/research/documents/finalreports/declercq_r40_mc_08720_final_report.pdf