Infections & Essential Oils

No Longer Working for Free

As our practice has grown, so has our administrative expenses, especially because we strive to meet every Indiana statute and exceed every professional standard. It can be difficult keeping costs at a point that clients can invest, while still covering costs. For the first several years of our practice, we participated in the Medicaid program and accepted payments from third party payers. Indiana Medicaid reimbursed a single prenatal at $30, and not often prior to 32 weeks because nurse-midwives are not primary providers within our state (violating Federal law, but that is another matter). Moving to a cash only practice was one of smartest decision we’ve ever made and was crucial in establishing a thriving practice.

At $30 a prenatal, the hourly rate of my nurse-midwife is not even compensated, not to mention the wages of our assistants and receptionist. No supplies were covered, no equipment, no payment for space, heat, phone or administrative costs. Medicaid is a huge loss to midwifery practices, unless such practices are willing to take clients late in pregnancy, offer very few visits and for very brief sessions, and include a number of procedures which are high ticket items. This opposes the midwifery-model-of-care. Midwives value time intensive and low interventive care. Unfortunately this does not turn a profit when working within the Medicaid program or when contracted with third party payers and consumers seeking the midwifery-model-of-care do not always appreciate the reality of this concept so seek care elsewhere.

Recently we trained a new administrative assistant in processing birth certificates. She entered the number of prenatal visits with one of our clients as 22. The system kicked back a response that this was entered in error because it was outside the standard. She sought advice and one of our midwives confirmed that this was an accurate number. This particular client was determined as high risk and so was provided close monitoring through her pregnancy. She was diagnosed with gestational diabetes and had a high risk finding in her blood screen. She was also at an advanced maternal age. The obstetrician we consulted for opinion on her blood screening felt she should be risked out of midwifery care entirely and offered a primary cesarean section at 38 weeks of pregnancy.

We offered the option of transferring to a medical practice and offered to continue as her primary providers with our own strategy. The benefits and risks of both were discussed, as well as our experience and expertise in working with the issues she was currently facing. She and her husband chose to continue in our care and so we extended twenty-two nurse-midwifery consultations and nearly as many nutritional consults, and we had a successful homebirth at 41 weeks of pregnancy. All of this – all her prenatal visits, nutritional consults, twice weekly non-stress tests, labor management, birth with two nurse-midwives and an assistant, postpartum home visits, and neonatal care through six weeks for total fee of approximately $5,500. This pregnancy would easily have exceeded 50 thousand dollars in a medical practice. We were honored to care for this family and are motivated to continue doing what we do because of outcomes such as this.

Did we push our luck? No. Our care extended the same management she would have had in any traditional practice, but because we invested heavily in her pregnancy and because she committed to optimizing her pregnancy, we succeeded in maintaining a very stable diabetic without any additional co-morbidity issues. This allowed us to approach her birth with minimal intervention. Extending a high level of care is not about the birth setting, but about the team. Technology travels. We live in a modern society. Investing with great expertise is the key.

Back to the point of this article, while midwifery care can offer a significantly lower cost than the standard medical model, should we work for free? Consumers have become accustomed to free healthcare, either while covered by Medicaid or by a third party payer. When insurance companies reduce their reimbursement, clients are unaware because they are seemingly unaffected. It is standard for homebirth-based nurses to be denied payment when claims are filed, or for various supplies and medications to be reimbursed below cost. The midwife in private practice must share her “professional earnings” to cover the cost of the entire team and its overhead.

Interestingly, while a large number of midwifery practices are working on a cash-only basis and more physician practices follow suit, some are recognizing the multitude of ways they give away their services for free. An article in the Houston Chronicle in February of 2003 (yes, more than ten years ago) discusses the expectation consumers have of phoning their provider for advice, a prescription or a work release but don’t want to pay for this service. In comparison, they appreciate when calling their attorney, during business hours, they will be billed by the minute. They have no expectation of obtaining such advice after hours.

A few years ago, our office reached out to a contractor for a service required in our practice and while the spouse worked to correct our issue after office hours, one of our nurse-midwives sat and talked to his wife. This started as a simple, friendly discussion and ended with the nurse-midwife diagnosing a medical concern, ordering labs, and providing a pharmaceutical at no cost to the wife. Without hesitation, the husband left a bill for several hundred dollars for his work. No one batted their eye at the irony, because one expects a plumber, electrician, or computer technician to charge for their work, but a midwife… well, we are expected to do this out of the kindness of our hearts.

I’ve toiled with this irony my entire career. We know this when we enter the field. We recognize we will be overworked and underpaid. We enjoy serving and don’t seek to become rich. As a business owner however, we must cover our expenses if we are going to continue to offer our services. Telemedicine is the new buzz word among Indiana legislature and certainly not a concept our practice is very familiar. This new and innovative concept seeks to extend care to clients via Skype or Go To Meetings. Some practices have started charging for email responses, or $5 a minute for phone calls. This Houston (2003) article states, “I think the patients know that if they are going to take a doctor’s time, they are going to have to pay for it,” Dr. Allen M. Dennison of Barrington, R.I. Is that really true?

Published more than a decade ago, this article states that the administrative costs of running a medical practice has grown tremendously (spoken even prior to the implementation of electronic health records) and “most primary-care doctors now spend on average of two to three hours a day on tasks for which they are not compensated, such as returning phone calls and filling out insurance forms,” (na, 2003, Houston Chronicle).

“If you call your attorney at 4 o’clock in the afternoon on a Friday, they are going to send you a bill. I don’t understand why I shouldn’t send a bill if someone wakes me out of a dead sleep at 4 a.m.” Dr. Paul Williams, past president of the Pennsylvania chapter of American Academy of Family Practitioners

There is the perception that if a practitioner charges for their time, we are “nickel-and-diming” our clients. At the same time, as operating costs increase and our resources are stretched, clients expectations don’t change. They still expect every call to be returned on their time table, prescriptions to be called in immediately, advice to be given freely so they are inconvenienced with having to visit the clinic, and medical records to be transferred same day. When we fail to meet these demands, complaints increase. Charging appropriately for our work would allow us to better meet the demands of our clients, and ultimately increase customer satisfaction. However, how does a midwife offer homebirth services to all who desire it, in all financial classes, and still meet the needs of all her clients?

Another irony that is commonly ignored is the fact that the high dollar incomes of physicians allows for a stay-at-home wife or a nanny and housekeeper. When a midwife, who are predominately all female, work outside the home and keep the hours required of a midwife, how does she satisfy the needs of her family and home when her income is less than what she made as a bedside nurse? After seven years in practice, and as the owner of this business, Dr. Lane has yet to earn what she did as a bedside nurse working only twenty-four hours per week, with full medical and retirement benefits.

This post offers no answers. The solution escapes us quite frankly. How does a practice offer the highest standard of care for nearly a year per client, twenty-four hours a day, with exceptionally well educated staff and a high staffing ratio, and with equipment that rivals a level one facility at a cost lower than the price of a website build, a set of orthodontic braces, a semester of college, or a nice landscaping job?

 

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Cultural Diversity & Midwifery

We had a mother a few years ago whose pregnancy duration far exceeded standard pregnancy parameters and it was an emotional event for a few of our nurses. Two in fact, no longer wanted to participate in her care and this became evident to the family, because ultimately we had to terminate our relationship with nurses not capable of supporting our practice model. The parent’s of this young pregnant mother assumed their discomfort was related to her being a teen mother who became pregnant outside of marriage. I was distraught that I had to let really great nurses go that were fearful of the repercussions of our litigious society and failed to recognize that this family felt judged for reasons many of us personally empathized, and genuinely desired to support. It seems through the years, I’ve been quite surprised by those who felt they had to ask if they would be “allowed” within our practice because of their culture, race, religion or sexual orientation. It is quite disheartening to think that any of those reasons would cause someone to think they may be excluded. We once had an African American couple ask if we would care for a “black family” and flabbergasted, I asked why they would even question that. Their response was that Thorntown is a small community and sometimes they are not welcomed to similar communities. My good friend who practices in Florida has shared with me that she’s had women of color in her practice share that their friends poke fun at them for birthing at home, claiming its “such a white thing to do!” A few times a year we get calls from same sex couples and again, to think one would be excluded for who they are is a bit astonishing to me.

There is well-documented racism within the healthcare community for which we must not remain naive. Most notably, the 1932 U.S. Public Health Services Tuskegee Syphilis Study on Untreated Syphilis in the Negro Male, in which federally funded investigators withheld available treatment from African American men with syphilis. This history of racial discrimination in fact, has created a reluctance among African Americans to participate in medical research or even to trust researchers and clinicians. Authors Boulware, Cooper, Ratner, LaVeist & Powe (2003) sought to discover if African Americans or white healthcare consumers were more distrusting of clinicians and hospitals. Overall, respondents did trust their physicians (71%) and trusted hospitals (70%), although fewer trusted their health plans (28%). Interestingly, black respondents were less likely to trust their physicians than whites, but more likely to trust their insurance plans. Black participants were more likely to report concerns about personal privacy and the potential for harmful experiments (Boulware, Cooper, Ratner, LaVeist & Powe, 2003). Similar findings were discovered by researchers Cohin (2003) and Corbie-Smith, Thomas, & George (2002).

The staff of Believe Midwifery Services, LLC are committed to serving a diverse population and are regularly educated in world views, cultural trends, and ethnic differences so that we may extend the most sensitive and respectful care available. Every single woman deserves safe and satisfying healthcare.

Boulware, L., Cooper, L., Ratner, L., LaVeist, T., & Powe, N. (2003). Race and trust in the health care system. Public Health Reports, 118, 358-365. Click here to view this article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497554/?tool=pubmed

Cohen, J. (2003). Disparities in health care: An overview. Academic Emergency Medicine, 10(11), 1155-1160. Click here to view this article: http://proquest.umi.com.ezproxy.midwives.org/pqdweb?index=0&sid=1&srchmode=1&vinst=PROD&fmt=6&startpage=-1&clientid=51766&vname=PQD&RQT=309&did=452629321&scaling=FULL&ts=1309535589&vtype=PQD&rqt=309&TS=1309536000&clientId=51766

Corbie-Smith, G., Thomas, S., & St. George, D. (2002). Distrust, race, and research. Archives of Internal Medicine, 162, 2458-2463. Click here to view this article: http://archinte.ama-assn.org/cgi/content/full/162/21/2458

Book Review: Clinical Aromatherapy by Jane Buckle

Jane Buckle has offered a second version of the book, Clinical Aromatherapy. This is one of the few evidence-based books for clinicians, but sadly the copyright is more than a decade old without a newer version available. For those looking for more than a simple pocket guide with suggested essential oils for various ailments, this is still a helpful resource. Jane Buckle holds a PhD and that mindset is evident within her book.

UnknownThe first few chapters are an introduction to aromatherapy and basic plant taxonomy, chemistry, extraction, biosynthesis and analysis, with subsequent topics on toxicity and contraindications. However, chapters four through twenty-five review various body systems and apply aromatherapy principles to the treatment of ailments within each system.

Each chapter offers an introductory discussion regarding the system itself and a review of the standard of care offered as of a decade ago from the worldview of modern medicine. The remaining portion of each chapter explores the available evidence available on the system under discussion. The endocrine chapter for example, offers a basic discussion of the intricacies of the body’s hormonal system, then discusses medical management and available resources, and finally presents a discussion on aromatherapy as it relates to premenstrual syndrome, menopause and diabetes.

The author clearly identifies evidence from anecdotal information, and when discussing either, she is thorough in her discussion. Anecdotal information for example will offer a history and most often, trace the origin of such recommendation to its rightful owner. While reading the text, there were certainly times where it was evident that the information printed is no longer valid and on only rare occasion, information within is quite simply, inaccurate. For example, the author defines the sexually transmitted disease, trichomoniasis, as a bacteria; when in fact, this is parasite. Details that may seem insignificant, but nonetheless, remind the reader to avoid using this single text as a Bible for directing how they may recommend essential oils within their own practice.

As a nurse-midwife with a passion for essential oils, this book was a wonderful find in that it is one of a limited number that offers scientific rationale for its recommendations. An intelligent discussion is offered, with a plethora of resources. It is not a book that offers recipes or gives suggestions on application, but as an educational resource for the healthcare practitioner seeking to expand their essential oil knowledge-base, this text is a good resource. It would be a true treasure if it were updated and if that day presents, I’ll be on the waiting list for purchasing my own copy.

Essential Oils for Hormone Balance

Premenstrual syndrome (PMS) and the symptoms surrounding peri-menopause are directly related hormone to hormone balance, or lack thereof, and many of these discomforts can be ameliorated with certain essential oils. Fluctuation in estrogen alone, occurring after ovulation and during menopause, can lead to profound mental and physical symptoms.

Premenstrual Syndrome

While it can sometimes be hard to admit, women have known for generations that for a few days each month, just prior to menses, many can become irrational, irritable, weepy and occasionally, violent. While the phenomenon is somewhat of a mystery, it is understood that the woman’s brain actually changes during this time leading to reactions she can not control (Alexander, 2001). The area deep within the limbic system involved with mood control has more estrogen receptors than other parts of the brain, which makes it more vulnerable to changes in estrogen levels. Interestingly, Alexander (2001) discovered that depending on the side of the brain more significantly effected, symptoms can alter. The left side often produces symptoms of depression and irritability, while the right side is associated with anger and negative emotion.

At the onset of one’s monthly cycle, levels of estrogen and endorphin interact with neurotransmitters serotonin, dopamine, and norepinephrine to keep mood fairly stable. When estrogen levels first begin to drop, immediately after ovulation, serotonin receptors are primed. Prior to menstruation, estrogen levels drop even further and the brain registers a withdraw of serotonin. During premenstrual syndrome, there is a fluctuation in the levels of endogenous opioids and serotonin which modern medicine treats with selective serotonin reuptake inhibitors (SSRIs). Women have found chocolate to also be an effective remedy, which has also been found to increase serotonin.

Aromatherapy for PMS

clary sage vintageEssential oils for the treatment of premenstrual syndrome are usually those which are thought to have an estrogen-like property, such as fennel, sage, or clary sage. Scotch pine and myrrh are also thought to have hormone-like activity. An old remedy for female hormone balance included sage, thyme and geranium. Aniseed is another essential oil found helpful for treating PMS.

Hormone imbalance can take several months to remedy, so essential oils should be applied daily for several months. When additional issues arise, women may benefit from individualizing their blend by adding specific oils for specific complaints to those previously suggested. Bergamot for example, can improve symptoms of depression and weepiness or angelica can improve violent and irrational behavior. Either of these could be added to a blend of fennel, thyme and geranium.

A study by Tzeng et al in 1991, suggested that the aqueous extract of geranium (Pelargonium graveolens) can inhibit platelet aggregation and therefore reduce extensive clotting which is common to peri-menopausal women. Another study by Han et al (2003) indicated that clary sage applied to the abdomen can reduce dysmenorrhea (several menstrual cramping). Aromatherapists have anecdotally found success with tarragon for women who display aggressive PMS.

Aromatherapy and Menopause

Depression is a major symptom of menopause, motivating many to seek hormone replacement therapy (HRT). Others fear the sequela of osteoporosis, while others are optimistic HRT will treat their hot flashes. Hormone replacement therapy has its own set of consequences, some more severe than others, but weight gain, bloating and breakthrough bleeding are common reasons for discontinuation.

Cessation of estrogen and progesterone production does not happen overnight. The interim imbalance can be tumultuous. Essential oils such as rose, cypress, or clary sage can be helpful when used in a spritzer around the face, neck, and shoulders during a hot flash. A few drops of peppermint added to the mix is wonderfully cooling. Essential oils that could be used for estrogen support include fennel, sage, and aniseed. Cypress can be helpful for night sweats, and angelica or lavender for insomnia. Juniper can reduce breast tenderness and fluid retention. Red clover supplements and black cohosh can also help tremendously as these phytoestrogens can help balance wildly fluctuating hormones.

Similar to PMS, using essential oils for balancing hormones during the peri-menopausal transition is best when done daily. It is suggested that rotating calming and estrogen-supporting essential oils, simply to prevent a reduced response over time.

Nurse-Midwives and Women’s Health

Nurse-midwives adore catching babies, but our speciality isn’t so limited. We are primary care providers for women and can assist in managing hormonal imbalances common to the monthly cycle and assist women who are transitioning into menopause. Make an appointment with your local nurse-midwife to discover how her counsel may optimize your current health.

A Midwife’s View of Menopause

Following the birth of our fifth child, my husband and I were immediately aware that our little Simon would be our last child. I’ve adored every minute of mothering and have embraced the transformation pregnancy and breastfeeding have brought to my mind, body and spirit. Now that I look forward to my future, post-babies, I choose to again to embrace the transformation by body will soon endure in menopause. As a midwife who treasures pregnancy and birth as a physiologic event, I can’t imagine viewing menopause in any other way. It too is physiologic and should be equally empowering.

While medicine defines menopause as a linear event and one not diagnosed until after the twelfth month of an absent menses, in reality, it is not typically so succinct. Tremors of the change can begin years prior to the attainment of the medical diagnosis, and in some ways I already recognize this in myself (having not quiet yet reached 40 years of age). I am finding I am sleeping less, but still flowing with creative juices, yet at the end of the day, I am realizing a new fatigue – an exhaustion really, to my core. I am also seeing the world differently, and responding with new insight. My self-image is transforming, and I am feeling a pull towards greater solitude. I am also starting to appreciate the abuse I have placed on my body, my adrenals, my pancreas, and my heart. It is time to nourish my body so that I can enter menopause in the most optimal state.

Nourishing Your Changing Body with Herbs

Red raspberry leaf is an herb that I have recommended to pregnant women for toning their uterus and optimizing their pregnancy and birth. Women who have experienced a prior cesarean section or have birthed a number of children previously, can particularly benefit from this tonifying herb.  For those trying to become pregnant, I’ve encouraged red raspberry leaf for its ability to enhance ovulation and implantation. As an infusion, red raspberry leaf can also nourish the ovaries and uterus of a women enduring the change of menopause. It is the go-to herb for women experiencing heavy bleeding during perimenopause.

vitex

Chasteberry (vitex)

Chaste berry, otherwise known as vitex, is another botanical I have recommended to a number of women and is in fact, the herb that motivated me to establish the Red Raspberry Boutique. As our primary care clientele increased and I began seeing more women with menstrual irregularities and infertility, I began encouraging it as a tonic. The success of chaste berry was astonishing, not only in enhancing conception but in regulating menses and even eliminating cyclic vaginal infections. These same attributes can assist the menopausal woman. Vitex is a slow-acting tonic, so regular use is necessary. It can also decrease bleeding which occurs from a uterine fibroid.

Dong Quai is a tincture that is becoming increasingly popular among our clientele. It has helped many find restful sleep, and may offer relief to those who have irregular cycles prior to the change.

Black haw and cramp bark are excellent allies for painful cramping that may occur with menses. Each are antispasmodics and astringents. Garden sage can also relieve pain from menstrual cramping. Motherwort can decrease cramping, but may encourage flooding. Valerian may be another option, and can assist a woman to sleep.

Maintaining a Satisfying Sexual Relationship

Counseling clients in matters of sexual intimacy is an integral part of women’s health, especially during the transformation of pregnancy. I’ve certainly been known to write a prescription or two for sexual intercourse, every other day, during the last few weeks of pregnancy. This issue is one that is often discussed in primary care appointments, and not always do clients initially appreciate its impact on their emotional health and overall happiness. Once clients feel comfortable opening up on this matter, their questions and concerns can easily dominate our consultation. In fact, it became so apparent that our clientele struggled with sexual dysfunction that we created a sexuality series that has been a tremendous hit. This certainly doesn’t change as women advance towards menopause. Nothing tones up the pelvic area more than regular sexual stimulation, and an orgasm can do wonders for one’s emotional health!

Vitamin E oil is encouraged in pregnant ladies who have not experienced birth previously, for preparing their perineum to stretch without tearing. Again, vitamin E oil can assist the menopausal woman enhance her intimate relationship as they tend to experience decreased blood flow to the area.

Stimulating Herbs

We see clients with gestational diabetics on a regular basis, each of whom I recommend supplement with chromium, and sometimes cinnamon. Our clients who suffer with poly-cystic ovarian syndrome receive a lot of the same advice. We have yet to have a mother risk out of our practice for inability to manager her gestational diabetes with diet and exercise, even those who required insulin in previous pregnancies. As we cinnamon sticksage, our bodies become less sensitive to the compensatory mechanisms our body offers for blood sugar regulation and diabetes becomes more prevalent (as well as rounder abdomens). Up to a teaspoon a day of ground cinnamon has proven beneficial for regulating blood sugars and decreasing dependence on insulin. There are herbalist who claim cinnamon can also assist in regulating the menstrual cycle and keep flooding at a minimum.

Floradix is another supplement frequently recommended to pregnant women who suffer with low hemoglobin levels, or anemia. It is an herbal recipe that is the best method of improving anemia that I have ever witnessed. It could be useful as well, for menopausal women who are experiencing heavy menses or who are experiencing increasing fatigue. Dandelion is a popular herb used for increasing the iron count, as well as yellow dock root. These should be taken throughout the day preferably, rather than one single dose.

Long chain fatty acids are vital for the development of the fetal brain, and the most important supplement during pregnancy and lactation in my opinion. We have a number of options within the boutique, with the doTerra wild orange flavor IQMega being one of the most favored due to the ease of which one can ingest it. Udo’s oil is among my most favorite and has been one of the highest qualities for many, many years along with 7 Sources. Flax seed is another excellent source of bioflavonoids, and used by menopausal women to reduce flooding. These must be fresh and uncooked however, so our clients typically sprinkle them on their morning cereal and then drink with a large class of milk. Others steep in water overnight and then drink upon awakening, seeds and all. Borage, black currant, and evening primrose oils are alternative options. Be sure to store appropriately.

Wild yam is an active ingredient in many balancing herbal and essential oil recipes. It too, can assist in progesterone production and therefore decrease menstrual flooding. Uva ursi, raspberry leaves, chaste berry, garden sage, and black haw bark are also helpful in reducing profuse bleeding. These can be infused individually, or combined to make a blend. Consume to one’s desire, at room temperature or cooler.

Shepherd’s purse has long been used by midwives for reducing postpartum bleeding, and can be utilized as well for menopausal women who are experiencing excessive bleeding. While herbs can nudge one’s body into optimal health, they are not resources for acute emergencies. Use them in combination with medical modalities if one is facing a life-threatening hemorrhage. The seed pods and flowers of shepherds purse can be used in tea, drank freely, and results should be evident in a matter of hours. Daily use can decrease bleeding caused by fibroids.

Zinc, iodine and B6 supplementation may also help decrease flooding, while avoiding aspirin, ibuprofen, large doses of vitamin C and herbs that thin the blood are also important.

Self-Identifying as a Nurse-Midwife

How we identify ourselves as nurse-midwives “has a direct effect on our licensure, accreditation, certification, practice, education, legislation, reimbursement; indeed, our very being” (Burst, 2010, p 406).  Helen Varney Burst makes argument in her 2010 article, Nurse-Midwifery Self-Identification and Autonomy, that identifying ourselves as a subset of nursing might be detrimental to obtaining autonomy as nurse-midwives.  This was a necessity in the infancy of our profession, in effort to give midwifery credibility in an otherwise medically dominated culture. The price was the loss of autonomy for midwifery.

Nurse-midwives & Professional Nursing Organizations

I suspect many are unaware that the nurse anesthetists and nurse-midwives predated, by decades, the nurse practitioners and clinical nurse specialists. Even I was unaware that the American College of Nurse-Midwives (ACNM) national certification program predated various American Nursing Association (ANA) certification programs. The American Nurses Credentialing Center (ANCC), a subsidiary of the ANA, provides certification in speciality practice areas such as to nurse practitioners (NP) and clinical specialists (CNS); however, they have been careful not to list nurse-midwifery among the specialities that they certify (Burst, 2010).

Now we are in 2010 and carry with us ambivalence about who we are because of the legacy we inherited from the compromises made a century ago. ~Helen Varney Burst, CNM

Burst (2010) discusses the ambiguity within our profession in that we have identified as midwives, yet not all are nurses, and we have defined ourselves as “an individual educated in the two disciplines of nursing and midwifery,” yet this implies nursing is not midwifery and midwifery is not nursing. We allow ourselves to be licensed as advanced practice nurses, but admittedly, nursing has been a strong ally in our rally for full scope authority practice.

The Consensus Model

The American College of Nurse-Midwives recognizes our organization as a nursing organization and in 2009, the ACNM endorsed the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education which clearly states CNMs are advance practice nurses. An important point I hadn’t considered is that in 2010, 38 states and the District of Columbia regulated nurse-midwives through their state board of nursing. Part of the intent of the Consensus Model was to eliminate barriers to practice when one moves out of state and must obtain a new license to practice; however, because nurse-midwives are regulated by boards of nursing in some states, boards of medicine or public health in others, and in still others, boards of midwifery, this isn’t a cure all for our profession’s dilemma. More importantly, “we have signed onto a document that in effects runs the risk of giving away what little autonomy we have achieved in licensure, accreditation, certification, and education” when states have freed themselves from the nursing profession (Burst, 2010, p 408).

“Until CNMs and CMs have separate midwifery licensure we are not autonomous and in control of our authority to practice midwifery.” ~Helen Varney Burst, CNM

The American Nurses Association is not of the same mindset of the American College of Nurse Midwives on all matters, or even of the same worldview. If we are to exist independently as a profession, Burst argues ardently, that we must also exist independently and autonomously as a profession.

Admittedly, as the Secretary of the Indiana ACNM Affiliate, I can testify to the fact that it is hard to have a voice as a midwife at the policy-making table except through the auspices of other professions which have louder voices simply through virtue of having greater numbers. Our profession is recognized as a subgroup of either nursing or medicine, and not appreciated as unique and independent in its own right. While working with other nursing groups, in our successes and failures, it is often discussed whether there is greater benefit or risk in joining the nursing troops or stepping out independently. In 1974, the ACNM Legislative Committee stated, “Separate statutory recognition is recommended as the basis for nurse-midwifery practice.”

One point made in the Burst (2010) article that testifies to the harm we’ve done in affiliating with nursing organizations is the ANA passing the resolution in 1984 requiring a master’s degree as the minimum qualification for entry to practice, yet those programs extending a graduate degree in public health or even midwifery would therefore not qualify. This may extend to the doctorate degree as well, with potential educational programs offering a doctorate in midwifery, rather than nursing, yet not being subsequently recognized in state legislature that may recognize only the DNP.

“We need to keep in mind our numbers are not a hindrance.” ~Helen Varney Burst, CNM

As a profession, it is important that we move forward as midwives, appreciating our own body of science, our own scope of practice, and working towards achieving our own goals. We certainly need to educate and collaborate with nursing and medicine, but the question Burst (2010) poses is, should we free ourselves from nursing to gain autonomy as midwives? Does proclaiming ourselves as advance practice nurses prevent us from attaining the goal of autonomous practice?

“I can and do subscribe to the concept that all health care professionals are interdependent in the provision of comprehensive health care. However, the concepts of interdependence, being a member of a team, and collaboration take on a very different meaning when one is a member of an autonomous profession.” ~Helen Varney Burst, CNM

Credentialing Confusion

I’ve been very proud to represent nursing and so this article is one that frankly, caught me a little off guard. There is great value in attaining the ability to extend care across the range of human conditions and I don’t know that our midwifery sisters always appreciate this concept. Nurse-midwifery in the United States followed the British model, as introduced by Mary Breckinridge, but in many countries, midwifery is entered directly. The United Kingdom has both nurse-midwives and direct entry midwives who meet the same midwifery competencies (Avery, Germano & Camune, 2010).

While proud to be a nurse, the unusual paradox of being educated in two professions and therefore regulated in a country that has a regulatory system that combines both federal and individual state laws, means not only are nurse-midwives regulated by various boards as mentioned previously, but we are given different authority based on the individual state and a plethora of credentials. One might be an “APN,” an “APRN,” or an “ARNP,” or the state may recognize the nurse midwife as a “CMW,” a “NW,” or a “CRNM,” and as I am told there is one particular state that credentials the nurse-midwife as a nurse-practitioner, an entirely different profession! Some states require both sets of credentials, such as APRN, CNM and if a midwife is licensed in two different states, she must change her credential based on which state she is working. The Consensus Model works to clarify licensure language and ease movement between states. Indiana sadly, is at the tail end of the group in advancing the Consensus Model recommendations (Avery et al., 2010).

ACNM offers professional resources to members on their website for addressing issues created by the Consensus Model and specifically how to prevent adoption of new laws or regulations that bring the regulation of midwifery under the board of nursing. Indiana currently regulates nurse-midwifery under the board of nursing, and regulates direct entry midwifery under the board of medicine.

References:

Avery, M. D., Germano, E., & Camune, B. (2010). Midwifery practice and nursing regulation: licensure, accreditation, certification, and education. Journal of Midwifery & Women’s Health, 55(5), 411-414.

Burst, H. V. (2010). Nurse-midwifery self-identification and autonomy. Journal of Midwifery & Women’s Health, 55(5), 406-407.

Williams, D. R. (2010). Consensus model for advanced practice registered nurse regulation: implications for midwives. Journal of Midwifery & Women’s Health, 55(5), 415-419.

Food for Thought

Food for Thought

"It is much more important to know what sort of patient has a disease than what sort of disease a patient has." Sir William Osler

Food for Thought

Happiness is underrated and critically important to health. Seriously! Unfortunately, many people just have no idea how to be happy. Aviva Romm

Food for Thought

Physicians simply do not have time to be what patients want them to be: open-minded, knowledgeable teachers and caregivers who can hear and understand their needs. Snyderman and Weil

Food for Thought #1

They say that time changes things. But you actually have to change them yourselves. Andy Warhol

Food for Thought

To think is easy. To act is hard. But the hardest thing in the world is to act in accordance with your thinking. Johann Wolfgang von Goether

Food for Thought

"Birth isn’t about avoiding one set of realities in favor of another. It’s about embracing all facets of birth--contradictory, messy, or unpleasant as some might be--as vital to the whole." Rixa Freeze PhD

Food for Thought

Why I appreciate being a certified nurse-midwife, as opposed to choosing another route for midwifery: I feel learning the science is vital so the art of midwifery is safe and effective. Dr. Penny Lane, nurse-midwife

Food for Thought

When the debate is lost, slander becomes the tool of the loser. Socrates

Food for Thought

To accomplish great things, we must not only act but also dream; not only plan, but also believe. Anatole France

Food for Thought

"Science and uncertainty are inseparable companions. Beware of those who are very certain about things. There are no absolute truths in biological sciences - only hypotheses... 'We need to train medical students and residents more in the art of uncertainty and less in the spirit that everything can be known or that it even needs to be known.'" Grimes (1986)

Food for Thought

American physicians are rewarded for doing things to patients, not for keeping them well. Grimes, 1986

Food for Thought

The false idol of technology. "Having a widget screwed into one's scalp has become an American birthright." Grimes, 1986

Food for Thought

"Between 1985 and 1987, a hospital instituted a successful program to reduce its cesarean rate. The rate fell from 18% to 12%, losing the hospital $1 million in revenues - no small sum in those days." Goer & Romano, 2012, p 37

Food for Thought

"Obstetricians are much more likely to perform a cesarean when they wrongly believe the baby weighs 4000 g or more based on sonographic estimates than when the baby actually weighs this much but the obstetrician did not suspect it." Goer & Romaro, 2012, p 35

Food for Thought

"If you play God, you will be blamed for natural disasters." Marsden Wagner (2006)

Food for Thought

An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you know and what you don't. Anatole France

Food for Thought #3

"Birth is not only about making babies. Birth also is about making mothers - strong, competent, capable mothers, who trust themselves and know their inner strength."

Barbara Katz Rothman PhD (1996)

Food for Thought #4

Believe there is always, always, always a way.

When you have exhausted all possibilities, remember this: you haven't. THOMAS EDISON

Food for Thought #5

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." Arthur Schopenhauer

Food for Thought #2

Yet you brought me safely from my mother’s womb and led me to trust you at my mother’s breast.

Psalm 22:9