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Meet the New DOR Intern - Katelyn Edel

Posted by Midwives Alliance on February 16th, 2016

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Katelyn EdelMy name is Katelyn Edel, and I am the new intern for the Department of Research, where I work closely with Bruce Ackerman, Jen Brown, and Sarita Bennett. 

In addition to my new role with MANA, I am currently a first-year student at the Brown University School of Public Health, where I am focusing on rural health policy and women’s health and working towards my MPH degree. I first contacted MANA because I was looking for a data set that I could use for my upcoming thesis project. I was very committed to the idea of a thesis topic that would not only fulfill Brown’s requirements, but that would also interest and inspire me – and the two most inspiring topics I could think of were midwifery and statistics. 

I have been interested in healthcare for quite awhile, and I have a particular passion for women’s health and their well-being. The intent behind nearly all of my work is to contribute to a world in which women are supported in their reproductive choices, regardless of whether those choices are made at home, in a hospital, or in a larger societal context. I am especially invested in ensuring access, choice, and quality services for women in underserved and low-resource communities, and finding better ways to deliver care to those populations. 

I am incredibly blessed to have grown up in a family that not only supports, but also celebrates, women’s choice. My brother and some of my cousins have been born at home, all with the caring skill that only a midwife can provide. In this sense, I feel that I am really fortunate to have been exposed to midwifery throughout my life, because in school I often find myself in academic or clinical settings where the wisdom of midwifery is not supported, although I look forward to the day that this changes. 

Which, finally, brings me to my enthusiasm and interest in evidence-based practice and research. I firmly believe in the power of data, which is why I think the MANA Statistics Project is so wonderful. MANA Stats is an incredible tool for midwives, for researchers, and for the general community, because it is a vehicle that can provide truly valuable scientific insight. With the DOR, I am helping to ensure that midwives are able to use MANA Stats in an effective way – essentially, I am a “Data Doula,” and I do a lot of Support Calls, Welcome Calls, and general follow-up with the midwives that are enrolled with MANA Stats. I think it’s important to have real, honest-to-goodness phone conversations with the new enrollees, or with contributors who may feel unprepared to use the MANA Stats software, because it creates a sense of community and of support. Long-term, I will be not only continuing my work as a Data Doula but also creating a handbook and other resources for future Data Doulas, which will be important as the MANA Statistics Project continues to grow. 

I’m really very happy to have the opportunity to work with MANA Stats from both ends, as a future researcher using it for my thesis, and as a Data Doula for the midwife-contributors. So far, my work has provided me with a sense of holistic understanding about the entire research process and that has proven to be an invaluable tool. I look forward to continuing my internship throughout the year, and I am especially excited about attending the MANA Conference in Atlanta! Everyday I am inspired by all of the wonderful people that I meet at MANA, and I am honored to be a part of this community. As I continue with school (and as I start the certification process to become a doula!) I hope to be able to contribute to MANA in a myriad of ways – first as an intern, but one day as a member. 

Waterbirth Safe For Babies, Finds New Research

Posted by Midwives Alliance on February 2nd, 2016

Largest Study on Waterbirth Finds No Harm to Babies

New Position Statement Compiles Waterbirth Research for Families, Providers

Many families consider waterbirth, but the 2014 American Congress of Obstetricians and Gynecologists/American Academy of Pediatrics (ACOG/AAP) guidelines recommend against this practice. Fortunately, new information and tools that can inform birthing people’s decision-making process were released in the past week. First, the largest research study in the US on waterbirth was published in the Journal of Midwifery and Women’s Health. Last week, a new position paper compiling the findings of this and other waterbirth research, Midwives Alliance and Citizens for Midwifery Position Statement on Water Immersion During Labor and Birth, was released by Citizens for Midwifery and Midwives Alliance, with the goal of informing families, health care providers, and policy makers. Jeanette McCulloch of BirthSwell interviewed the article researchers Marit L. Bovbjerg PhD, Melissa Cheyney PhD, CPM, LDM and Courtney Everson MA, PhD and position paper authors Nasima Pfaffl MA, Jill Breen CPM, CLC and Justine Clegg MS, LM, CPM, to help inform childbirth educators and others on how to interpret the findings and the position paper for their clients. 

Jeanette McCulloch: What were the key findings of the research?

Marit Bovbjerg PhD: We found that being born underwater did not confer any excess risk to the baby. Babies born underwater were no more likely than those not born in water to have a low five-minute Apgar score, or require hospitalization or neonatal intensive care (NICU) admission. We also found no evidence that waterbirth is associated with neonatal death; on the contrary, in our sample of 6,534 babies born in water, there were no cases of death that could be attributed to being born in water. This indicates that, for low-risk mothers whose labors proceed normally, water immersion is generally a safe pain management option.

For the pregnant parent, we found that waterbirth was not associated with infection or hospitalization. Surprisingly, though, we found that mothers in the waterbirth group were slightly (11%) more likely to experience perineal tearing.  This finding is contrary to numerous previously-published studies, most of which reported a lower rate of tearing in mothers choosing waterbirth. The question of trauma (tearing), then, is still unresolved, and any future studies on waterbirth should make this outcome a focus.

However, even if the small, but increased risk of tearing that we reported is replicated in other studies, many individuals may still choose to labor and birth in water for the labor pain relief described in numerous other studies. For those who want to avoid epidurals and other drugs, spending a portion of active labor in a pool or tub may facilitate an unmedicated physiologic birth with all the benefits we know that confers for both mother and baby (ACNM, MANA, and NACPM, 2012; Buckley, 2014)1  Each childbearing family should weigh the potential benefits (reduction of labor pain) and the potential risks (possible increased risk of tearing), and decide based on their own values and preferences. The main upside of our research is that clients can explore these issues without worrying about whether or not waterbirth will negatively affect their babies. It won’t.

JMc: This research was based on home and birth center births from the MANA Stats dataset.   Are the outcomes applicable to the hospital setting?

Melissa Cheyney PhD, CPM, LDM: As Marit just highlighted, our findings suggest that waterbirth is a reasonably safe option for use in low-risk, low-intervention births, especially when the risks associated with other forms of pharmacologic pain management, like epidural and spinal anesthesia, are considered. Because hospitals that do allow waterbirths generally only provide this option to low-risk women, we believe these results could be applied in other settings. We know that there are several hospitals here in Oregon, for example, that have active waterbirth programs and are currently tracking their outcomes. Their preliminary impressions are that babies born in water are at no greater risk, and that water immersion as a pain management strategy helps to decrease rates of epidural use.  

It is possible that training and experience level of the provider makes a difference in outcomes. In our sample (based on MANA Stats) 35 percent of births occurred under water. This means that many of the midwives who contribute data to MANA Stats are very experienced at monitoring and attending births in the water. While some hospitals do offer waterbirth programs, it is currently unclear how frequently births happen under water in these facilities. One difference between the provider populations represented in our study, who are almost all CPMs and CNM/CMs, and those who might attend waterbirths in the hospital could be variability in exposure to, and experience with, labor and delivery management in the water. 

That said, when we look at the balance of evidence from international studies, our study, and preliminary data from hospitals in the US, we believe that findings are converging around the sentiment that while waterbirth may not confer any particular safety benefit for babies, it almost certainly confers no added risk to the neonate in low-risk pregnancies. Families should be allowed to choose waterbirth from among a range of pain management options. We would like to see waterbirth offered more widely across the US in all birth settings. 

JMc: The MANA and CfM Position Statement on Water Immersion During Labor and Birth brings together peer reviewed evidence and the clinical experience of midwives who provide waterbirth. How can childbirth educators use this document to support clients considering waterbirth?         

Justine Clegg MS, LM, CPM: Because laboring and birthing in water is popular with clients, especially those choosing to birth at home and in birth centers, childbirth educators, doulas, midwives and midwifery educators need to be well versed in the issue to answer consumer questions, and provide the most current information to help families decide what is best for them. 

The Position Paper is a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits, and recommendations for success. 

Jill Breen CPM, CLC: First, I think the research we cite will help to dispel some of the publicized concerns (drowning, cord avulsion, respiratory distress) about safety to the baby since no deaths in over 6500 waterbirths were attributable to being in the water.  

The position paper also makes it clear that the experience level of the practitioner may be an important factor in the safety of waterbirth. Childbirth educators can help clients identify experienced practitioners in their area or help families develop questions that they can ask to choose a site and practitioner for their planned waterbirth. 

In the position paper, Jennie Joseph LM, CPM identifies another potential outcome important to raise with some clients. Because waterbirth may reduce stress and promote physiologic birth, thereby reducing the likelihood of unnecessary procedures and disruptions of the newborn transition and parent/infant attachment, access to waterbirth may be an important tool to address disparities in outcomes for families of color.

JMc: What role should consumer choice and shared decision making play in waterbirth? 

Nasima Pfaffl MA: Just as in all birth choices, shared decision making is key. 

One of the primary tenants of the Midwives Model of Care is individualized counseling and education. For all birthing decisions, a midwife and the birthing family can explore the available evidence, the client’s needs, values and preferences, and the midwives experience, comfort level and clinical recommendations during shared decision making.

For example, let’s look at the conflicting findings across all waterbirth literature for vaginal tearing. The small increased risk of perineal trauma could be a deciding factor for some clients, but a small concern for those who place greater emphasis on the research findings that show overall high rates of satisfaction with waterbirth. The warmth, mobility, comfort, privacy and pain relieving attributes of laboring and birthing in water may be a deciding factor for others. 

For families who  want a waterbirth, I recommend when possible, choosing a practitioner with a high degree of comfort, knowledge, and experience with waterbirth. A knowledgeable practitioner will be familiar and comfortable with the differences between water and air birth (such as evaluating blood loss in water) and should be able to discuss these with their client. 

JMc: How do findings from the recently released paper on waterbirth compare to the current ACOG/AAP guidelines?

Courtney Everson MA, PhD: The ACOG/AAP guidelines (Committee Opinion No. 594), released in April 2014, were a primary impetus for this study. In those guidelines, ACOG and AAP acknowledge the safety and potential benefits (i.e., pain management) of laboring in water, but also state that the safety of birthing in water has not yet been established and, thus, waterbirth is not recommended.  

At the time the guidelines were written, many small- to medium-sized cohort studies from Europe were published suggesting that waterbirth was safe. However, the ACOG/AAP guidelines did not include this evidence, and cited instead primarily case series and case reports. Case series/reports are not studies; rather, they are a description of what happened to a few patients (laboring women/newborns, in this scenario). There is no comparison group and the results are based on a very small sample, which means that robust conclusions about the exposure (in this scenario, waterbirth) cannot be drawn. Knowing, for example, that one baby ended up in the NICU from the case group of 10 waterbirths is not helpful unless you also know how many babies went to the NICU from a similar group of non-waterbirths.  

In the guidelines, ACOG and AAP recognize the limitations of available research, stating, “Before examining available evidence concerning immersion during childbirth, it is important to recognize limitations of studies and evidence in this area” (ACOG/AAP, 2014, 1). We believe that our research has addressed these limitations, and now offers good evidence for the safety of waterbirth. 

Our sample of 6,521 women (6,534 neonates), with a comparison group of 10,252 women (10,290 neonates) who did not choose waterbirth, makes this the largest study on waterbirth to-date. Additionally, this is the first large waterbirth study in a US population, which is important because of the acknowledged uniqueness of both the US healthcare system and the US population. 

With this publication, there is now a study in a US population examining neonatal and maternal outcomes for more than 6500 waterbirths. Contrary to conclusions drawn in the ACOG/AAP guidelines, findings from this study demonstrate that waterbirth confers no additional risk for babies. Future position statements and clinical guidelines should reflect the balance of evidence on waterbirth to-date, which suggests that birth in the water is a safe and viable option for low-risk pregnancies and, accordingly, should be offered as an option to childbearing families. 


1ACNM, MANA, NACPM. (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. Journal of Midwifery & Women’s Health, 57(5), 529–532. http://doi.org/10.1111/j.1542-2011.2012.00218.x

Buckley, S. (2015). Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families.

Photo credit: Megan Hannon Photography courtesy Izabella de Barbaro


About the authors

Marit BovbjergMarit Bovbjerg PhD, MS is a reproductive and health services epidemiologist at Oregon State University. Dr. Bovbjerg's research focuses on maternity care in the US, with a sideline into physical activity during pregnancy/postpartum. In her non-work time, she likes to knit, grow vegetables, cook, and play outside (hiking, running, biking, etc.) She does not like to sit still and in fact avoids doing so whenever possible. Marit and her husband are attempting to turn three exuberant children into responsible adults, a task at which they might, on a good day, be slowly succeeding (though likely through no fault of their own). They live in an untidy but cheerfully-painted house in rural Oregon, and enjoy vacationing in places with abundant outdoor activities but few people.

Jill Breen

Jill Breen CPM, CLC has been serving women, babies and families for 37 years as a homebirth midwife and natural family health consultant. A MANA member since 1984, Jill has served on the Board of Directors in several positions including President, as well as on several working committees, and currently is Communications Chair. She is a founding member of Midwives of Maine, a statewide, inclusive association of midwives since 1981. Jill is a Home Birth Summit delegate active on the Collaboration Task Force. She was an appointee to the Maine Governor’s Advisory Committee on Rulemaking regarding certified midwives and was a member of the Maine CDC Inter-professional Work Group addressing flow of care across birth settings. The Maine Best Practice Recommendations for Handoff Communication During Transport from a Home or Freestanding Birth Center to a Hospital Setting was approved by the Commissioner of Health and Human Services in November, 2014. Jill writes, speaks, and mentors including as a guest lecturer at University of Maine. She is the mother of 6 children, all born at home, and has 9 grandchildren, all born into the hands of midwives, including her own.

Missy CheneyMelissa 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.

Justine CleggJustine Clegg MS, LM, CPM is a Florida Licensed Midwife, Licensed Mental Health Counselor, and Certified Lactation Counselor with over 35 years experience in maternal-child healthcare, homebirth and education. She lives in Miami, FL and Asheville, NC with husband Jim Brinkman. She is currently AME Board secretary, and most recently Academic Director for Commonsense Childbirth School of Midwifery in FL. As Midwives Association of Florida “founding mother” (1979) Justine helped write and pass Florida’s midwifery licensing law, start the South Florida School of Midwifery, and was Administrative Director in the 1980s. She established a 3 year midwifery degree program at Miami Dade Community College, served as Midwifery Chair and Professor 1993-2008, and earned an Endowed Chair (2003). As Council of Licensed Midwifery Chair from 1993-2001, she helped write Florida’s midwifery practice rules. She is on Miami-Dade County Fetal and Infant Mortality Review’s team since 1997, and FIMR Chair, 2004-2008. A former Board member of MEAC and NACPM, she helped create NARM’s certification program in the 1990s. As Midwives Association of Florida CEU coordinator, she helps host MAF’s state conferences every two years. As a member of the North Carolina Midwives Alliance, Justine was MANA Region 3 conference CEU coordinator August 2011 in Cary, NC, and supports the initiative to legalize CPMs in North Carolina. She is the Midwives Alliance Documents Chair. Her 3 children and 6 grandchildren make her a “granny midwife.”

Courtney Everson

Courtney L. Everson MA, PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also the Director of Research Education for the Midwives Alliance of North America (MANA) Division of Research (DOR); Co-founder and Vice President of the Oregon Doula Association (ODA); a Research Working Group (RWG) member of the Academic Collaborative for Integrative Health (ACIH); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson's research and teaching specializations include: maternal-child health; human childbirth; adolescent pregnancy and parenting; psychosocial stress; social support; doula care; midwifery care; research and clinical ethics; evidence-informed practice; collaborative care models; mixed methodologies; health inequities; cultural competency/humility; social justice; and underserved populations. She actively publishes in academic forums, and is an invited, avid speaker at local, national and international venues.

Jeanette McCullochJeanette 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.

Nasime Pfaffl

Nasima Pfaffl MA is a medical sociologist with a focus on social movements and women’s health. She is a second generation home birth mom. She is the current president of Citizens for Midwifery and has served on the board since 2006. She worked for the Midwifery Education Accreditation Council as their Accreditation Coordinator. She served on the MAMA Campaign steering committee, on the Birth Network National Board, the Coalition for Improving Maternity Services Leadership Team (Board), and as the Grassroots Advocates Committee Co-Chair and Survey Team Lead for The Birth Survey. Nasima focuses on coalition building and utilizing capacity building technologies and tools to make midwifery advocacy organizations stronger, more effective and able to create the change needed in our broken maternity care system. She lives in Florida with her son, daughters and husband. Nasima can be reached by email.

 

MANA and CfM release new Joint Position Statement on Waterbirth

Posted by Midwives Alliance on January 28th, 2016

Mother and baby in birthing tub

The MANA and CfM Joint Position Statement on Water Immersion During Labor and Birth is a position paper written for a broad audience including midwives and other birthcare professionals, consumers, doulas, childbirth educators, and policy makers. It is co-authored by the Midwives Alliance of North America and Citizens for Midwifery. A year of collaborative work has produced a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits and recommendations for success. With over 80 citations, including the new study "Maternal & Newborn Outcomes Following Immersion During Waterbirth" by Bovbjerg, Cheyney and Everson, which utilized data from the MANA Statistics project, and research by waterbirth activist Barbara Harper, the position paper is a reference guide to the evidence for the safety of water immersion during labor and birth.

How does the new study using data from the MANA Statistics project help us better understand waterbirth?

The research of Bovbjerg, Cheyney and Everson helps to dispel some of the more publicized concerns about the safety of waterbirth to the baby, including drowning, cord avulsion and respiratory distress. No deaths in over 6500 water births were attributable to being born under water. There was also no additional risk of maternal infection or hemorrhage.

The MANA Stats study showed that 35% of over 18,000 home and birth center births occurred in water, demonstrating that the midwives contributing to MANA Stats have considerable experience attending and monitoring births in water. The experience level of the practitioner may be an important factor in the safety of waterbirth.

6,521 waterbirths, including 13 sets of twins, 29 breeches and 327 VBACs, were compared with 10,252 mothers who did not choose waterbirth, making this the largest comparative study on waterbirth to-date. Additionally, this is the first large waterbirth study of a US population, with its unique healthcare system and demographics.

While the ACOG/AAP Committee Opinion of April, 2014, not recommending water immersion for birth, acknowledged the limitations of the available research on waterbirth, this large US study fills that gap and gives us the best evidence to-date on the safety of birthing in water.

"Maternal & Newborn Outcomes Following Immersion During Waterbirth" by Bovbjerg et al, was published Jan. 20, 2016 in the Journal of Midwifery & Women's Health. JMWH has generously agreed to make this research article open access, so midwives, birth workers, and consumers can read it without needing to buy a subscription to the Journal.

What else can we learn from the MANA/CfM Joint Position Statement?

Evidence and experience show us that mothers choose waterbirth for several reasons. They report feeling more relaxed, in control, able to move more freely, and, notably, relief from pain. Especially considering the risks of pharmacologic pain management such as epidural and spinal anesthesia, water immersion during labor and birth may be safer for mother and baby. "In addition, because water immersion facilitates normal physiologic birth it may also be associated with other beneficial health outcomes for mother and baby, including decreased need for intervention during labor and reduced incidence of surgical/instrumental delivery." (quote from the statement)

As in all healthcare and birthcare decisions informed consent/refusal and shared decision making with your care provider is key to determining what is best for each family. The Joint Position Statement can help in these ways:

  • describes the benefits of water immersion for mother and baby,
  • suggests how these benefits may improve outcomes for families of color,
  • addresses consumer choice and shared decision making,
  • considers client values and individual needs and,
  • lists factors that promote safety and success.

The practical and professional pearls of wisdom make the Factors that Promote Safety and Success section an invaluable tool when considering and planning a waterbirth and we are pleased to be able to share them with you.

The conclusion: Many families consider water immersion during labor and birth a valuable option. Current research and experience show waterbirth to be safe for mothers and babies and may provide benefits to both. "MANA and CfM support the use of water immersion during labor and birth, and believe it should be made available to birthing families across all settings. MANA and CfM encourage all care providers to become educated about the safe use of water immersion during labor and birth, and to engage in a shared decision making process when discussing the option of water immersion with their clients." (quote from the statement)

The authors of the joint position statement are:

Jill Breen, CPM, CLC; Justine Clegg, CPM, LM, MS; Nasima Pfaffl, MA, President CfM; Amy Smith, CPM

Thanks also to the consultants on the statement: 

Barbara Harper, RN, CD, CCE; Holly Horan, MA; Jennie Joseph, LM, CPM, CEO of Commonsense Childbirth, Inc.; Indra Lusero, JD, MA; Jeanette McCulloch, IBCLC; Shafia M. Monroe, MPH, DEM, CDT, President and CEO of the International Center for Traditional Childbearing (ICTC).

About the author

Jill Breen, CPM, CLC, has been serving women, babies and families for 37 years as a homebirth midwife and natural family health consultant in central Maine. She has 6 children and 9 grandchildren, all born into the hands of midwives including her own. She has served MANA in several capacities, including as President, and is currently Communications Chair. She is a member of the Home Birth Summit Collaboration Taskforce.

Meet Nicole, MANA Director of Events

Posted by Midwives Alliance on January 20th, 2016

Nicole Marie White

Hello MANA members and friends,

I am your Director of Events, Nicole Marie White, CPM. I am from Michigan and currently working as a member of the Coalition to License Certified Professional Midwives in Michigan. We just passed the house in December!

My great great grandma was a midwife.

Her name was Fannie Bush. I didn't know about her until after I began attending births in 2001. I took the long road apprenticing with several midwives in different practices and finally I attended Maternidad La Luz for the year program. I am so glad I did. I was surprised at how much I loved the clinic setting, collaborating with other midwives and getting to provide access of care to many more people then I was accustomed to in the home birth setting. I started my studies in San Francisco, CA and was able to participate in an awesome program at St. Elizabeth's where we did labor support and child birth education for the teenage mothers who resided there. After 10 months, I gained an apprenticeship in Santa Cruz. I know both of those experiences colored my understanding of midwifery care and the impact that quality maternity care has on every mother and baby. I just finished a 2 year stint working in a bustling, adorable home birth practice in Traverse City, MI. Prior to that I had a fellowship in the city of Detroit to work towards lowering the infant mortality in the city. I also have spent time working as a midwife in Uganda and Haiti.

I’m thrilled to be on the MANA board.

"Midwives are the warriors on the front line of health care battling to ensure that women survive childbirth and babies are born safely even in the most marginalized areas." (World Health Organization) My interest in spreading the midwifery model of care is what fuels me. I truly believe midwives are the answer to much of the maternal health crisis we see here in the US and abroad. I look forward to when the CPM is recognized and licensed all over the USA.

What do I do at MANA?

I am Director of Events, so that means I am at the helm of our fabulous Annual Conference!

Conference is such a corner stone to MANA and I am honored to be part of the amazing team that makes it happen. SHINE was such a bright way to begin my MANA journey and this year in Atlanta will prove to be another fantastic time. Conference is so important and many people look forward to it every year. Time to connect, celebrate, learn, see old friends and make new ones. Midwives are such a unique group! We are all different but share a common, deep thread. I loved when Deborah Kaley accepted her MANA educator award in Albuquerque and she said all her friends are midwives, former midwives, current midwives or future midwives. It made me smile and be grateful to be in a room full of friends.

Please reach out to me if you want to be more involved, have questions or suggestions, this is your conference! As MANA is your organization this is your conference! Thank you for doing this work. I am in deep appreciation for all of you that have worked so hard to create this solid foundation.

I am currently in the airport in Paris on my way to Greece. I am headed to Greece to work with Circle of Health International ( COHI ) in the refugee camps. Please check them out for more info! And check my website if you want to get to know me better. Thank you for welcoming me into the folds of such a rich, important organization.

See you in October at MANA16 in Atlanta, Georgia!

~ Nicole

New and Sometimes Conflicting Research on Out-of-Hospital Birth

Posted by Midwives Alliance on January 7th, 2016

In the past month, two new studies have been released - one in the New England Journal of Medicine (NEJM), the other in the Canadian Medical Association Journal (CMAJ) - examining out-of-hospital birth outcomes. The CMAJ study examined 2006-09 provincial health records while the NEJM study analyzed two years of Oregon vital statistics data. What makes the NEJM study unique is that the Oregon birth certificate now allows researchers and others to track the intended place of birth, providing for more accurate categorization of the outcome of transfers.

The two studies both found that families that choose out-of-hospital birth experience fewer interventions, including labor augmentation, assisted vaginal births, cesarean births, and episiotomies.

Both studies also found that the absolute risk of adverse neonatal outcomes is small regardless of setting. However, the CMAJ study found equivalent risk between home and hospital settings, while the NEJM study found that planned out-of-hospital births were associated with an excess of less than 1 fetal death per 1000 deliveries -- a small but statistically significant difference. 

Resources:

Media coverage. MANA has compiled resources for midwives reviewing the outcomes and providing guidance for interpretation for families. 

First, here's a piece in Forbes that provides balanced coverage (note the article - like many - refers to "home birth" while the study combined birth center and home birth data together). 

MANA provided expert commentary to a number of the recent news articles, including The New York Times and The Washington Post.

Expanded coverage at Science and Sensibility. The official blog of Lamaze International has provided balanced coverage of the New England Journal of Medicine research. In this post, Henci Goer compares and contrasts this newest study with other recent home birth analyses. Missy Cheyney, Chair of the Midwives Alliance Division of Research, provides guidance for families interpreting the new research in this post.

Model transfer guidelines. The authors of the NEJM article call for increased collaboration and integration of out-of-hospital providers into the maternal health care system. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital, developed by the collaboration committee of the Home Birth Summit, are an important and practical tool to increase integration.

The guidelines were designed to facilitate the safe and mutually respectful transfer of care of a woman and her family from a planned home birth to the hospital. The model blueprint was created as the result of a unique collaboration among physicians, midwives, nurses and consumers.

To learn more or endorse the guidelines, visit here.

News From the DOR: Implementing Evidence-Informed Practice During Midwifery Care

Posted by Midwives Alliance on November 12th, 2015

We hear the terms “evidence-based practice” (EBP) or “evidence-informed practice” (EIP) used often in the healthcare world, being cited as an expected and central component of high-quality care delivery. But what do these terms really mean? There is a misconception that in EBP/EIP approaches, “research evidence” automatically equates to “what I should do in practice”. This, however, is simply not true. EBP/EIP rests in the triad intersection between the best available research with your professional expertise as the practitioner alongside the client’s individual values, needs, and context. Figure 1 (below) visually represents what we are striving for when we say EBP or EIP, in ultimate commitment to improved client care, informed choice, and shared decision-making models.

Evidence-informed Practice Triad

 

You may be thinking: okay, I definitely have expertise as a midwife, and I feel I have a good understanding of my client’s unique needs, but how do I integrate research into practice?  A great place to start is with a series of modules on the Principles of Evidence Informed Practice from the University of Minnesota. These modules are self-paced, free of charge, geared towards busy practitioners, and thus intended to be short and sweet, ranging from just a mere 15 minutes to 30 minutes of your time. The series includes: Section I - Overview of Evidence Informed Practice; Section II – Types of Research; Section III – Using Evidence in Practice; and Section IV – Understanding Research & Statistics; plus resources and guiding sheets to help you implement evidence-informed practice during client care. Advance your professional self and check out these modules.

Finally, how do you find research to integrate? There are many peer-reviewed journals and scholarly databases to help you in your search. A few core ones to consider (many of which are open access!) are:

Google Scholar

PubMed   

BioMed Central

BMC Pregnancy & Childbirth

Cochrane Reviews   

Directory of Open Access Journals

PLOS One

North American Journal of Medical Sciences

HighWire

ERIC: Institute for Educational Sciences (collection: midwifery)

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Courtney Everson About the author

Courtney L. Everson, PhD, is the Director of Research Education for the Midwives Alliance Division of Research, a Biocultural Medical Anthropologist and the Graduate Dean at the Midwives College of Utah (MCU). Dr. Everson is also the Vice President of the Oregon Doula Association (ODA), an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC), and serves on the Board of Directors for the Australasian Professional Doula Regulatory Association and Doulas Supporting Teens. Her research and teaching specializations are in maternal-child health; adolescent pregnancy/parenting; psychosocial stress; social support; doula care; midwifery care; research & clinical ethics; collaborative care models; health inequities; and social justice.

Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

Posted by Midwives Alliance on October 2nd, 2015

Questions about the education levels and routes to certification for Certified Professional Midwives often play a role in policy discussions about birth providers, but little current evidence has been available to inform these conversations. 

A new article in the Journal of Midwifery and Women’s Health takes a close look at data from the NARM 2011 Survey. We asked Melissa Cheyney, lead author of the article, to share with us this FAQ. This piece was developed to inform midwives, consumers, and policy makers on the outcomes.

Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

The demographics, education levels, routes to certification, and practice characteristics of currently practicing CPMs are assessed in a new article released September 18, 2015 in the Journal of Midwifery and Women’s Health.

The article Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey is authored by Melissa Cheyney and colleagues and uses  data collected from the 2011 North American Registry of Midwives (NARM) Survey. (Find the abstract here: Cheyney, M., Olsen, C., Bovbjerg, M., Everson, C., Darragh, I. and Potter, B. (2015), Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey. Journal of Midwifery & Women’s Health.)

What was the primary purpose of the study?

No data describing CPMs currently exist in the literature, though they attend the majority of home births in the United States. The study was designed to begin to fill this gap. Specifically, it aimed to answer three research questions: 

1) Who are CPMs in the United States, and how are they getting their educations?

2) Are there differences between CPMs practicing in regulated and unregulated states in terms of training routes or non-midwifery education levels?

3) Who are CPMs serving and how do they practice?

In addition, the project aimed to assess the degree to which US CPMs meet the ICM education standards. A concurrent, non-research goal was to provide updated information about the CPM credential, since this information does not currently appear in the peer-reviewed literature.

How about the response rate? How many currently practicing CPMs responded to the survey?

The initial invitation was sent to 1,391 CPMs, and 849 (61%) responded. Because the survey was not originally designed for research purposes, the original survey respondents were sent an email explicitly requesting consent to have their data used for research. Of the 849 initial respondents, 568 provided consent for their responses to be analyzed; 281 did not respond. The final response rate was 41%.

Is it possible to generalize to the entire population of practicing CPMs, given the response rate of 41%?

Very likely yes, because the researchers also completed something called a non-response bias analysis. This entailed calling a random 10% subsample of the initial non-respondents and asking them an abbreviated version of the survey over the phone. Because the original respondents and the non-respondent group did not differ significantly in any key characteristics or responses, the findings presented in the study very likely accurately reflect the population of currently practicing CPMs.

What did the study find regarding non-midwifery education levels for CPMs?

More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor’s degree or greater. Only 0.5% of respondents (n=3) did not have high school degrees or the equivalent in 2011.

How long do CPMs spend in training prior to taking on the role of primary midwife?

CPMs spent a median of 3 years in training before attending births as a primary midwife.  Sixty one percent met the International Confederation of Midwives (ICM)-recommended 3 years of training, however, 38.9% of currently practicing CPMs did not.

This is at least partially explained by the fact that “grand” CPMs (CPMs who have been practicing for 25 years or more) comprise 19% of currently-practicing CPMs. Midwives who began practicing this long ago, before certification was available, often began primary practice very early in their careers and sometimes with little or no formal training. These CPMs describe being taught by birth, other midwives, and home-birth-friendly physicians as they pieced together their training in the 1970s and 1980s, before formal training or credentialing opportunities existed. As the profession has matured and formal training routes have been developed, it is much less common today for CPMs to enter primary practice before the 3-year mark.

In addition, because of the variability in volume of births at training sites, the study also found that student midwives training in high-volume birth centers can easily attend more than 100 births per year during their 1 to 2-year internships, allowing them to acquiring their CPM prior to the internationally-recommended 3-year training period. Conversely, student midwives in low-volume home birth apprenticeships might take several years to qualify to sit for the NARM examination having attended fewer than 100 births. The authors conclude that within the current competency-based system of CPM education in the United States, length of time to primary practice may not always be the most useful way of estimating competency. Some combination of volume and years in training may be more helpful in this regard.

So what pathways to certification are CPMs actually using?

The study found that 48.5% utilized the Portfolio Evaluation Process (PEP), 36.9% graduated from a Midwifery Education and Accreditation Council (MEAC)-accredited school, 14.5% were already licensed by a state as a direct-entry midwife, and 0.7% were already a CNM or CM. However, the researchers stress that routes to certification (that is how CPMs apply to sit for the NARM examination) should not be confused with how CPMs get trained. The study found that CPMs reported a blended education pathway that commonly involved a mixture of MEAC-accredited schooling and apprenticeship in home and birth center practices, regardless of which (MEAC- or PEP-route, for example) pathway to certification the midwives used to acquire permission to sit for the NARM examination.

Debates over the CPM credential have focused on the relative merits or limitations of the two primary routes to certification: graduation from a MEAC-accredited school or successful completion of the PEP. How does this study inform that discussion?

This study found that CPM training is far more complex than this dichotomy suggests. While respondents largely cited either the PEP or MEAC route to certification, a closer look at how midwives are getting their educations showed that the vast majority of respondents combined multiple training opportunities over the course of their educations, depending on two key variables: 1) whether or not they lived in a regulated state with an accredited school and 2) whether they had sufficient funds to attend one of these schools for the entirety of their educations. Although each applicant must designate a single pathway on their NARM application, economic and legal barriers cause many to create a patchwork training trajectory that combine aspects of MEAC and PEP. As a result, the authors would argue that the "MEAC or PEP" dichotomy is a false one.

What did the study find regarding differences between CPMs living in regulated vs. unregulated states?

The regulatory status of the CPM credential in each respondent’s state was found to have an association with the certification pathway chosen by midwives. Analyses showed a significant difference (P < .001) between certification pathways chosen by midwives residing in regulated versus unregulated states. The PEP process was more likely to be used in unregulated states, while MEAC-accredited schools and the state licensed midwife pathway were more likely to be used in states where CPMs are licensed and regulated.

What about the demographic characteristics of CPMs? How diverse is the population of providers?

One-fifth (21%) of respondents identified as midwives of color. While nearly one-third (31.8%) of CPM respondents reported that 95% or more of the clients they serve are white, 5.2% serve populations that are 90% or more women of color. CPMs of color were also found to be significantly more likely to serve clients of color. Given the finding that midwives’ self-reported ethnicity/cultural group is strongly associated with the client population served, the authors identify the lack of racial, ethnic, and cultural diversity in the profession as a major concern.

Cheyney and colleagues state that while, “it is unclear from our results whether midwives of color seek clients of color or vice versa, it is clear that without more midwives of color, childbearing families of color will have limited access to culturally-matched midwifery care and particularly to home birth services. Home and birth center birth may currently be a white middle-class phenomenon in the United States not because women of color prefer hospital birth, but because they have been systematically excluded from choice in childbearing by larger structures of inequality.” 

The same economic and legal barriers that impact all CPM education may be disproportionately impacting midwifery candidates of color. These barriers, compounded with larger issues of systemic inequality, may be sufficient to bar entry to the profession for many potential midwives of color.

Melissa CheneyAbout the author

Melissa Cheyney, PhD, CPM, LDM is the Chair of the Midwives Alliance Division of Research, and an Associate Professor of Medical Anthropology and Reproductive Biology in the Department of Anthropology at Oregon State University (OSU). She received her doctorate from the University of Oregon in 2005, where her research examined the U.S. Homebirth Movement and Midwifery Models of Care. Dr. Cheyney is a Certified Professional Midwife, Director of the Reproductive Health Laboratory at OSU, and Chair of the Board of Direct-entry Midwifery for the State of Oregon. She is also the author of the recently published ethnography, Born at Home by Wadsworth Press. Her research specializations are in midwifery care, interprofessional collaboration, reproductive biology, maternal-child health, homebirth, and medical anthropology.

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

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“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.

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