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Hormonal Impacts of Health Disparities on Birth Outcomes

Posted by Midwives Alliance on September 24th, 2015

The Cycle of Stress and Poor Birth Outcomes

Midwives Alliance of North America, in collaboration with ICTC, ICAN, and Elephant Circle is releasing this Executive Summary of Existing Research on Racial Disparities in Birth Outcomes and Racial Discrimination as an Independent Risk Factor Affecting Maternal, Infant, and Child Health. This infographic graphically depicts key findings and offers solutions.

New Research on Planned Home VBAC in the United States: Interview with Study Author Melissa Cheyney, PhD, CPM, LDM on the Implications for Midwives

Posted by Midwives Alliance on September 15th, 2015


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. 

To help the birth-professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Missy Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, PhD, CNM, and co-authored by Marit Bovbjerg, PhD, MS, and Lawrence M. Leeman, MD, MPH, can be found in an online-only version here

The first part of the interview is currently available in a guest blog at Science and Sensibility. In that post, which you can read here, Missy shares the findings and her recommendations for parents and policy makers. Missy shares advice specific to midwives, based on the study’s findings, here at the MANA blog. Read on to learn more.  

Jeanette: So, what advice do you have for midwives working with a family who is considering an HBAC?

Missy: I think it is important to look very closely at the mortality and uterine rupture findings presented in the paper [the study found five deaths overall in the TOLAC sample, with three deemed unrelated to the mother having had a previous cesarean]. If we look at the two instances of confirmed uterine rupture (confirmed upon cesarean section), neither of those babies died. The midwives attending these mothers were monitoring very closely during labor and caught, early on, that something was going awry, as in decreased heart tone variability and a non-progressive labor pattern. They transferred, there was a repeat cesarean, and mother and baby were discharged in excellent condition three days after their births. In the other two cases of presumed uterine rupture (no cesarean, so no confirmation), trouble was not detected until very, very late in the process, there was no time to transfer, and both babies were born at home, but could not be resuscitated. Both of those babies died. 

The MANA Stats 2.0 form had a question that asked midwives how frequently they monitored. The midwives who said their client was attempting a TOLAC did not, in many cases, also indicate on the form that they listened more frequently. Now, part of that is because the question was not asked in an ideal way, but I will say that an overall trend in our mortality case-review process is examining the degree to which some midwives are listening and whether we are listening sufficiently. I said this last year in my presentation at the MANA 2014 conference: you have got to really be on heart tones, especially if the mother has any risk factors, including a longer than average labor or a clear plateau. What we have learned from the mortality case review - which is what we did here, we case-reviewed every one of these deaths - is that midwives who were listening very diligently (so through contractions and then for 30 seconds afterwards with increasing frequency as labor intensifies), can catch early signs of decreasing variability and respond appropriately.

The other thing that's significant is that in the cases with fatal ruptures, those mothers had plateaued, so their first or second stages were stalled for a prolonged period of time, and this can be a problem. It fits with what we know from the larger body of the literature that if you have a mother that is contracting adequately and her cervix is not changing or the baby is not moving down, the strength of those contractions will cause something to open, something to move. We're hoping it will be the cervix, but if the cervix is not opening, we need to be concerned that it might be the scar. I would advise midwives attending any woman who's attempting an HBAC to be aware that a plateau itself can be a risk factor; to listen more frequently; and to have a tighter protocol around transfer. And that means acknowledging that women attempting a TOLAC are higher risk than a multiparous woman without a previously scarred uterus. I'm not saying that they are so high risk that we can never consider them for home birth. In fact, I think that some women desiring a TOLAC are excellent candidates for HBAC. But I would say, we've got to listen more carefully and engage in very individualized, shared decision-making related to the location of the placenta, length of time to the hospital, our relationships with hospital providers in our communities once we arrive, length of time between pregnancies, etc.

I think that the vast majority of midwives attending HBACs in the United States are doing these things. Yet a study like this gives us all the invaluable opportunity to stop, turn the lens inward, and think critically about how we can make our practices as safe as possible. We all know that there is no joy, no empowerment as we typically hope for our clients in an HBAC, when there is also a loss.

Jeanette: And do you recommend any additional prenatal screening?

Missy: I do. It was concerning to us (the authors) that nearly 25 percent of women in the TOLAC group did not receive an ultrasound for placental location and diagnosis of accreta prior to attempting a TOLAC at home. Given that the rate of abnormal placentation is rising, an obstetrical ultrasound should be standard of care for any woman with a prior cesarean. Also, less than 40% of the women in the TOLAC group had GDM testing. Some of this may be reflective of the difficulty in some states of acquiring lab tests and ultrasounds, and this needs to be addressed immediately. Women are going to continue to want to attempt VBACs, and HBACs more specifically. They need access to adequate prenatal screening. If we are caring for someone who already has the known risk factor of a previously scarred uterus, we want to make sure that we have normal placentation, and we want to know that she doesn't have any other comorbidities because there can be a compounding of risk, like we see in the twin VBAC case [presented in the study]. 

This study makes me think about how important it is that all maternity care providers work together to make birth as safe and empowering for families as possible, wherever we practice, and whether or not we ourselves would ever consider having or attending a home birth after cesarean.

To read the complete interview, visit our guest post at Science and Sensibility.

About the authors


Melissa Cheyney, PhD CPM LDM, is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.


Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.

Overview of the MANA Core Competencies Revisions

Posted by Midwives Alliance on September 13th, 2015

In 2008 the International Confederation of Midwives took a serious global look at the health of mothers and babies and developed a series of core documents to support the growth and utilization of midwives throughout the world. In June 2011 the ICM Council endorsed new global midwifery standards for education, regulation, and association – the "3 pillars" for the profession. The World Health Organization uses the ICM Core Competencies to inform midwifery organizations and government agencies to improve the health of mothers and babies world-wide.

In March 2013 the MANA Document Committee prepared a side-by-side comparison document of the ICM and MANA Core Competencies to identify where these two documents were aligned and where they differed. At this time both ACNM and MEAC were engaged in similar work.

The goals for the MANA Core Competencies revision were:

  • to bring them in line with the ICM Core Competencies as they apply to US midwifery, and
  • to make our language inclusive and welcoming to all who seek midwifery care.

Bringing the Core Competencies In Line With ICM Core Competencies

Examples of changes made to the Core Competencies:

  • Inclusion of environmental concerns such as access to clean water. Although this is often a concern in developing countries, there are areas in the US where pollution makes a community water supply unsafe.
  • Including the ICM Core Competencies concerning abortion that apply to US midwifery, with sensitivity to the politically controversial nature of this topic, and that relate to providing information and support for decision making regarding timing of pregnancies and resources for counseling and referral.
  • Expanding cultural awareness and sensitivity to the needs of communities of color and the LGBTQ community: Human rights and their effects on the health of individuals, including issues such as domestic violence, genital circumcision, gender equity, gender identity and expression, and how their expression affects health outcomes.

Making Our Language Inclusive and Welcoming To All Who Seek Midwifery Care

The MANA Core Competencies is a policy-level document and should address the full scope of any midwife’s potential practice. With that in mind, MANA opted to revise the Core Competencies to reflect all of the clients MANA midwives serve. The group that worked on these Core Competencies, like all our documents, included members of the Document Committee and the Board. After moving through the various steps and being reviewed by many MANA members as well as the entire MANA board, input on the final draft was solicited from Indra Lusero, JD, genderqueer parent and former Director of the Transgender Military Initiative; from Shafia M. Monroe, MPH, DEM, CDT, Founder and President of the International Center for Traditional Childbearing; and from the other Allied Midwifery Organizations including MEAC, NARM, NACPM, AME and CfM. We received suggestions and additions which we incorporated. The revised Core Competencies were approved via consensus decision of the full MANA board.

MANA is the national midwifery organization that represents the "Big Tent" where all midwives can feel valued and find support for their work. MANA is keenly aware of the social determinants of health. There are many issues of disparities to marginalized communities, such as the disparities in pregnancy outcomes among communities of color, and culturally inclusive issues and language reflect our goal of creating a document that can speak to all the diverse communities across the nation who can benefit from midwifery care.

Whereas pregnancy, birth and breastfeeding are unique to the female sex, there are those who seek midwifery care who do not gender identify as women. Increasingly, health care providers are needing to develop a basic level competency to understand the difference between sex and gender reality and an awareness that there is not a simple binary regarding both sex and gender, that there are more than two manifestations in human reproduction and in the psychology of gender identification.

Considering the national initiatives challenging health care professionals to provide gender neutral services and gender inclusive health care materials, we committed to a document reflective of these national trends and consistent with our values. In the process of crafting these revisions to our Core Competencies, many of the midwives involved found ourselves undergoing a paradigm shift and realized that many of these issues and practices apply more broadly to include other family members. Changing to gender neutral language reaffirms the midwives’ goal with relationship to the whole family system.

Inclusion is about membership and belonging. It is a process that acknowledges and supports the meaning of equal worth and equal rights. Inclusion promotes the growth of self-esteem. Inclusive language helps us all learn to be more aware, sensitive and humble to the needs of each family system and the devastating effects of marginalization. No individual wants to be singled out or identified as "different" or less worthy. As long as a single client is excluded from the midwifery community, all clients are potentially vulnerable to discriminatory treatment.

About the author

Justine Clegg, MS, LM, CPM, is Association of Midwifery Educators Board President. A Florida Licensed Midwife since 1987, she is Academic Director and Faculty for Commonsense Childbirth School of Midwifery since 2009 and Miami-Dade Community College Midwifery Director/faculty emeritus (1993-2008). Former Florida Council of Licensed Midwifery Chair (1993-2001) and Miami FIMR committee chair (2004-2009), she is also a licensed Mental Health Counselor and Certified Lactation Counselor. She graduated from the South Florida School of Midwifery and earned her MS from Florida International University. She served on the MEAC and NACPM Boards.

MANA's Access and Equity Committee

Posted by Midwives Alliance on September 1st, 2015

The Access and Equity Committee is a new MANA initiative to address systemic issues impacting midwifery and those seeking midwifery care. "Access" and "equity" are both words that capture the essence of this work: access = the right or opportunity to use or benefit from something; equity = the quality of being fair and impartial. As a midwife, you know that the right or opportunity to use or benefit from midwifery has not been fair or impartial. This is true for many, layered reasons:

  • state laws criminalize some forms of midwifery;
  • state scope of practice laws make it hard to practice the midwifery model of care;
  • insurance companies don’t include midwives as covered providers;
  • insurance commissions interpret "adequate networks" without considering midwives or place of birth;
  • state agencies regulate midwives using an obstetric model not made for midwifery;
  • federal grants and loans for education aren’t available for all midwifery educational paths.

The list could certainly go on, and each of these issues is compounded by how the right or opportunity to use or benefit from a wide range of things has not been fair or impartial when it comes to race, class, gender, sexual orientation, national origin, gender expression, region, language, and more. This is the intersection where the Division of Access and Equity works.

One strategy we will use in this effort is to increase the capacity of midwives to connect with their clients about these issues. To this end MANA has established a strategic partnership with Elephant Circle with the goal of charting a course for a stronger and more diverse political base for physiologic birth and access to the midwifery model. This partnership deliberately combines a professional association (MANA) with a grassroots, consumer-based, non-profit (Elephant Circle).

Elephant Circle has found, in organizing and legislative work for maternity care, that consumers are most effectively mobilized by their midwives. Consumers often feel a strong loyalty and commitment to their midwives, and when that passion is channeled into advocacy efforts it can be very effective. Connecting consumers and midwives in coalition as policy-collaborators is a deliberate strategy to increase political power. Midwives don’t hold as much political power as medical providers in existing health systems for a variety of reasons, not the least of which is sheer numbers (less midwives, less consumers of midwifery care).

The dominant model of political advocacy among healthcare providers is professional associations, and it is essential that midwives have healthy professional associations as a result. However, as minority providers, that advocacy model (professional associations) reinforces the power imbalance, keeping the "voice" for midwifery and physiologic birth small. Building an alliance between midwives and consumers adds sheer numbers, increases political strength, and moves the forum from a place where medical providers have an advantage (professional associations) to one where midwives have an advantage (consumer loyalty and passion).

Make sure to connect with the Access and Equity Committee this fall in New Mexico to learn more and get involved. Look for more articles and updates including the infographic on Physiologic Birth for African American Women, and the "Executive Summary of Existing Research on Racial Disparities in Birth Outcomes" created by ICTC, ICAN, MANA and Elephant Circle coming out soon. Share your resources with us at, and we will share resources with you! Here are a few:

  1. Take a short test at Project Implicit.
  2. Watch a video at BeyondWhiteness.
  3. Learn more about health care licensing boards in this Tool Kit from the Citizen Advocacy Center.
  4. Learn about The Speaking Race to Power Fellowship, which will connect and support leaders who want to develop generative ways of breaking through the current bottlenecks of race and power in the reproductive health, rights, and justice movement.
About the author

Indra Lusero, Esq., works as an organizer, trainer, and lawyer practicing family formation and regulatory law in Colorado. Indra’s publications include “Challenging Hospital VBAC Bans Through Tort Liability” and “Making the Midwife Impossible: How the Structure of Maternity Care Harms the Practice of Home Birth Midwifery.” Indra went to law school after attending a MANA conference in 2005 where folks lamented not having a “hot shot team of lawyers” who could help defend midwives. Indra has endeavored to develop just such a team.

Aviva Romm on the Impact of Midwifery Care on Lifelong Health

Posted by Midwives Alliance on August 18th, 2015

We are incredibly excited to have the honor of hosting Dr. Aviva Romm at this year's MANA conference, Shine, in Albuquerque, New Mexico. We took this opportunity to talk with her about why she thinks midwifery care can improve lifelong health, the impact of interprofessional tensions between maternity health providers, and critical opportunities for midwives to seize now.

MANA: Why have you chosen to present at Midwives Alliance of North America?

AVIVA: When I was asked to speak at MANA this year, aside from just being incredibly honored and grateful, I realized it was such a timely opportunity for me to be able to talk with midwives about something that's very important. As midwives, we are so focused on the importance of prenatal care toward birth outcome that we miss another great opportunity – the impact of pre-conception, prenatal and infancy on the lifelong health for our children.

We know that by the time a baby is born, he or she already has at least 300 environmental chemicals measurable in his or her umbilical cord. We know that early prenatal nutrition can determine a person’s predisposition to everything from eczema and allergies in young children, to believe it or not, diabetes, heart disease, stroke, and cancer, in adults. As midwives, bringing a greater awareness of this to periconception is a powerful way to bridge midwifery with lifelong public health and make a difference.

MANA: What do you believe would be the optimal relationship between families, midwives, and physicians?

AVIVA: I have long believed that the optimal relationship is a seamless one, where there's no separation between midwifery care and the medical model. I’m not saying that midwifery as a model should be subsumed by medicine or that midwifery has to emulate or become part of the way the medical model works. But there has to be a system where families don't perceive a separation in their care. This would optimize the experience of pregnancy and childbirth for women, helping them to make the best choice in where they want to have babies. One of the things I've observed as a midwife for 25 years, and also as a physician, is that women will ultimately birth where they feel the safest. For a lot of women, there's a conflict there. They don't actually feel that a hospital or a birthing center is the safest.

They are concerned, and rightly so, that the medical model dominates there, that they'll be subjected to interventions that they don't want but really can't fend off, whereas they don't necessarily feel entirely safe at home, either. Home isn't their natural first choice. Home birth becomes a reactive choice. For some of those women, the fear factor can determine the physiology of birth. Fear at birth can interfere with the process. I've seen women with this sort of underlying, insidious fear, which may not even be conscious. Sometimes as midwives we pick it up, but don't really know exactly what to do with it, and it sort of drives a transport in some way. Maybe there's a really prolonged labor or difficulty pushing, difficulty opening up and relaxing. It's that fear. I feel like if we took that dichotomy between home or hospital out of the equation and made that seamless, it would make the choice easier for women. Of course this assumes that we're working in a culture where hospital and birthing center births are reliable for women as places where they can go and have the birth that they really want to whenever possible, barring some kind of obvious medical complication.

I also feel that the schism between home and hospital sometimes leads midwives at home to make choices that aren't always in the best interests of the birth outcome. They're afraid to transport to the hospital. Having practiced in an illegal midwifery state for about 15 of my 20+ years as a midwife, I've observed many times where a midwife stayed home a little too long and there were complications that didn't have to happen but did, out of a fear of transport. A seamless system allows for things like ease of transport and emergency services that are specifically designed for midwives practicing at home.

MANA: As more states pass midwifery legislation and more midwives become licensed and provide care at home and in birth centers, how do you see the future of midwifery? We'd especially appreciate hearing your perspective on the integration of midwifery into the mainstream maternal health care system in the US. Do you see any downsides to home birth midwifery becoming integrated into our healthcare system?

AVIVA: I am all for midwives becoming more integrated into the mainstream maternal health system. We've actually seen that already, for the most part, with certified nurse midwives. I do have concerns that the legislated midwifery runs the risk of becoming "med-wifery," so I think the question becomes, how can we preserve the valuable traditional midwifery arts of midwifery while expanding women’s access to midwives and also how can we, as midwives, inform changes in the medical model.

Good examples would be how long a mom can be in labor or how long membranes can be ruptured, or how old or young she can be, or how much weight she has or hasn't gained. All of these kinds of parameters may seem set in stone to the medical model, but in actuality they shift over time and may have some arbitrary aspects to them. Another example would be how far advanced in pregnancy a mom can be before an induction is required rather than just something that happens according to set parameters in the medical model, and is now required for midwives to participate in. I think we're still in the infancy of what this kind of dialogue all looks like.

I've met and talked with many midwives from states that have licensure and feel that they're really in a good situation, that they've got sort of the best of both worlds. I've also met midwives and moms who are frustrated with the limitations placed on them, but sort of accept it as a necessary evil, if you will, to serve the most numbers of moms in the best way knowing that some moms who could be having more natural births, or possibly home births, are getting marginalized by rules. We have to keep our fingers on the pulse of it and try not to lose too much of our art in favor of the benefits that we get. It is a necessary trade-off that I understand that we all make. I'm excited to see where it goes.

MANA: At the 2015 MANA National Conference you are speaking on Shining a Light on Midwives in PeriConception Care, As Upstream as Healthcare Gets. Can you tell us more about the concept of periconception care?

AVIVA: Peri-conception care means the care that women are getting around the time of conception. To my knowledge, most midwives aren't reaching out into their communities or being reached by their communities before pregnancy. We know that in the 3 months or so prior to pregnancy so much can happen that sets the tone for pregnancy health and for what exposures baby might get in that early prenatal period, in that first 6-8 weeks of exposures when so much of the baby's nervous system, immune system, and organ development is happening, in that embryo genesis period.

Ideally, prenatal care would start in the pre-conception period with teaching mom about environmental exposures that she can avoid, possibly even working with moms around detoxification programs if they've had significant exposures. For example, if we know that they have a high mercury level based on testing, or we know that they have elevated homocysteine, which is a serum marker of inflammation that is related to increased risk of miscarriage, preeclampsia, placental abruption, and other problems.

The weight at which a mom becomes pregnant can have an impact on her health. Whether she's obese or whether she's underweight, it can set determinative factors in the baby for how the baby uses sugar and stores fat, not just while the mom is pregnant with that baby, but actually for the baby's entire life. We can have an impact on whether that baby develops heart disease, diabetes, strokes, and Alzheimer's. This is very significant and is a well-worked out science.

MANA: How do you see midwifery care differing from traditional medical care in periconception?

AVIVA: The American College of Obstetrics and Gynecology has recently recognized and emphasized the need for periconception care. But most obstetricians are just not doing it; their knowledge isn't there nor is the time.

As midwives, we can take the lead on this. For example we can make nutrition, and not just calories and protein counting and what micro-nutrients a woman needs, but really true, good food, a part of our midwifery curricula. Right now, the rates of obesity in the United States are reaching about 50%. We have an enormous obesity problem in our kids that also translates to high cholesterol, increased risk for cardiovascular disease and chronic inflammation and all the diseases that are associated with that, such as autoimmune diseases and Alzheimer's.

As midwives, we have an opportunity to do what we do best, which is to do, and teach, what's natural and healthy. That includes foods and awareness of ecological issues. As a whole, our profession tends to be much more green-oriented than the medical model. If we can bring that green orientation in our personal lives into our profession, we'd be way ahead of what the mainstream model has already said is one of the pressing agendas for obstetrics and for pregnant women.


Aviva Romm About the author

Aviva Romm, MD, is a Board Certified Family Physician, midwife, herbalist and the creator of Herbal Medicine for Women, a distance course with nearly 1000 students around the world, and Healthiest Kids University, also with nearly 1000 students. Dr. Romm is a leader in the revolution to transform the current medical system into one that respects the intrinsic healing capacities of the body and nature - while helping women take their health into their own hands. Her areas of research include botanical medicine with a focus on the needs of women and children, improving maternity care models, mind-body medicine, and the impact of environment on health. She is a gardener, artist, and visionary physician, as well as the mother of 4 grown children and grandmother of two — all 6 born at home.