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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.

15 Questions To Ask Before Choosing a Midwifery Path and Program

Posted by Midwives Alliance on July 21st, 2015

What midwifery credential should I choose? How can I tell if a midwifery school is right for me? As a practicing midwife, I am asked these questions by potential students as they decide between becoming a certified nurse midwife or certified professional midwife and when trying to choose a midwifery program.

I have gathered together the 15 questions I often ask potential students to consider as they make their decisions. Give yourself a few minutes, jot down your answers, and don't think too hard about any one question! You might be surprised at some of your answers. I hope these help you find the path that is right for you.

Choosing a path

Where do you want to practice? Consider both the place of birth - home, hospital or birth center - and the state or states you want to practice in. Research the license/credential requirements for the state and place of birth you'd prefer.

Who do you want to serve? Teen mothers, low income families, a small rural community, a big city busy practice with other midwives - who do you dream of serving?

What are the laws concerning midwifery (and student midwifery) in your community? Is it legal for a CNM to attend home birth? Can CPMs practice legally? Where? Do you need to register with anyone? Do you need to be enrolled in a school program to attend births as a student midwife? Can CNM student midwives have an internship with an out of hospital midwife?

Do you want to be able to move about the country and work in a wide variety of settings? Nurse midwifery may be more flexible when moving a lot, and also has the advantage of being able to work as a nurse as well.

Choosing a program

Are you interested in a Nurse Midwifery program? a Certified Professional Midwife program? Portfolio Evaluation Process? or a MEAC (Midwifery Education Accreditation Council) approved program?

Are you able to relocate to go to midwifery school? Do you have the resources to move and attend a midwifery school in another community? Is there an at-distance or online alternative?

Are you able to organize yourself and learn independently? Would a program that offers few "extras" and where you would need to work independently be a good fit? Would you be more comfortable with a structured program, that includes a clear plan for success? Do you want to work with your local midwifery community to learn in an apprenticeship model? Do the programs you are looking at have "perks" - support groups, libraries, database search engines, writing labs, or other extras?

Do you enjoy group learning activities? Do the programs you are looking at offer an opportunity to build community with other student midwives?

Does the program you are interested in offer clinical internships in your own community? Is your local community large enough for you to find a midwife preceptor who can help you finish your clinical requirements? Do your local hospitals offer Nurse Midwife internships? Does your program help you find a preceptor?

Do you need to complete any portion of your academic program before beginning your clinical training? Some programs, and some mentor midwives require that you complete up to a year of academics before starting clinicals.

How many of the students who start the program or apprenticeship you are considering finish, and go on to pass the credential and/or licensing exams?

Finding your resources

What are your financial, emotional, spiritual resources? What is your community support like? Does your family support your chosen work? Can they manage living "on call" with you? Are they concerned about liability issues?

Do you need a midwifery program that has federal financial aid? Nurse Midwifery and some MEAC approved programs offer Federal Financial Aid. Some MEAC approved programs do not offer aid but are much less expensive than those that do.

Do you have the time necessary to commit to midwifery training? Do you have time in your life for rigorous academic and hands-on demands? Can you be on call? Part time or full time? How much flexibility do you need?

Will you need to work while you are in midwifery training? Is it realistic? What is the expectation of the midwife you are working with or the program you will be attending?

 

I hope these questions have helped you to become clearer about how to choose a midwifery path that is right for you. Becoming a midwife is often a winding path, challenging at times, but rewarding! Good luck to you all!

 

About the author

Treesa McLean, LM, is a homebirth and birth center midwife and has been involved in the birth community as a consumer, an advocate, and a birth professional for more than 30 years. She teaches a workshop "Becoming a California Licensed Midwife" and has been the preceptor for a number of student midwives.

Prison and Birth

Posted by Midwives Alliance on July 21st, 2015

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Desiree Robles, a student midwife at Midwives College of Utah, shares with the MANA community the current state of maternity care for incarcerated women in the United States, along with policy recommendations for improving outcomes for mothers and babies. This post is a part of our student midwife guest post series. Are you a student? Please consider sharing a guest post with us! Contact MANA at publicaffairs@mana.org for more information.

Pregnancy and birth have the remarkable ability to be a common process for all women, regardless of economic status, race, or culture. They can occur at any time in a woman's reproductive life, including when they are sentenced to time in jail or prison. How these instances are handled in the United States is the subject of controversy and varies greatly depending on location but, collectively, is in need of reform. In the United States, incarcerated pregnant women deal with several reproductive issues that need to be addressed, including lack of proper prenatal care and nutrition, use of restraints during transport, labor, and postpartum, and a lack of birth education and support.

Despite the importance of prenatal care and proper nutrition during pregnancy, many inmates are not guaranteed access to them. According to the Committee on Health Care for Underserved Women (CHCUW), thirty-eight states have failed to institute policies requiring that incarcerated pregnant women receive basic prenatal care. In addition, forty-one states do not require prenatal nutrition counseling or do not ensure that these women receive proper nutrition (2011). What is important to note is that, according to a study done by Martin et al. in 1997, prisons are required to provide all pregnant inmates with appropriate prenatal care. However, according to a Women's and Children's Health Policy Center publication, less than half of correctional systems require screening of new female inmates for pregnancy and STD's (2000). Even with more than half of the United States correctional facilities not providing the proper prenatal care and nutrition for these inmates, some of these same women may still be at the same high risk or may actually be better off than if they were pregnant at home. A study done by Clarke et al. points out that pregnancies among incarcerated inmates are usually unplanned, high risk, and have poor outcomes because of, among other things, lack of or failure to access prenatal care and many of these women having poor nutrition (2006). Thankfully, many studies, including one done by Martin et al., have found that incarceration allows these women to have improved maternal and fetal health thanks to access to shelter and regular meals (1997). It is important that we implement screening protocols for incoming inmates at all correctional facilities so that their reproductive health can be addressed if need be, as well as making sure these inmates receive the proper care needed if they are found to be pregnant. 

Using restraints on pregnant inmates during the process of labor is a sensitive issue that has been the subject of scrutiny for years. There have been various studies that have delved into the adverse effects of restraining women in labor both physically and psychologically. While progress has been made in stopping the use of restraints on pregnant inmates, according to the Committee on Health Care for Underserved Women, thirty-six states and the Immigration and Customs Enforcement agency of the Department of Homeland Security have failed to limit the use of restraints on pregnant women during transportation, labor and delivery, and postpartum (2011). Use of "shackling," as it is called, causes discomfort for the pregnant inmate during a time when she is most vulnerable and many times the officers present are male. In an article done by Anderson, there is implication that birth transport often results in numerous medical and mental health complications, thanks to the security precautions used, including shackling. These precautions increase instances of injury and stress while stress in itself can cause complications in labor. Also, the women have limited movement, which adds discomfort and restricts their ability to protect themselves in instances such as falling (2003). An Amnesty International article brings to attention the traumatizing experiences of shackling on the laboring inmates. These included having their legs shackled to their bed post for almost the entirety of their labor which, again, caused restricted movement and hindered their ability to position themselves in more favorable positions during labor (2000). To add to their distress, according to Codd, women in prison many times give birth to their babies who are taken away almost immediately or at discharge from maternity ward, causing the mother much distress and robbing the baby of their mother's important breast milk (2004). Laboring inmates deal with these stressful situations that, while slowly being resolved, would be helped, in part, with childbirth education and support from, at the very least, female officers during labor. 

Birth education and support for pregnant inmates is lacking in many correctional facilities but are excellent resources that would greatly benefit these vulnerable women. According to Hotelling, with the right support and prenatal care, expectant new mothers often discard lifestyle behaviors which would compromise the health of their babies. Some programs have been initiated to provide physical and mental health care to incarcerated women. These programs depend on help from volunteers, grant money, and various organizations coming together in order to thrive (2008). The Bell et al. study noted that what is needed for incarcerated pregnant women is comprehensive programs that include enhanced prenatal care services in the community and greater transitional resources. This would be ideal, given that most women are incarcerated for smaller crimes with shorter sentences than men (2004). A great place to start would be birth education and breastfeeding workshops. In a study by Huang et al., pregnant inmates showed positive views on pregnancy and link it to a new start for them as mothers and in their life in general (2012). Childbirth education and support for pregnant inmates should be available at all correctional facilities as a way to help these women deal with the stress of pregnancy in an already stressful situation for the sake of their health and future as well as their children's.

Pregnancy during incarceration happens whether correctional facilities want it to or not. For this reason, protocols should be made mandatory at all correctional facilities to screen for pregnancy, as well as STD's, to ensure the health of their inmates. While prenatal care is required for all pregnant inmates, screening for pregnancy is not. This very important loop hole should not occur in our correctional facilities, as early prenatal care and nutrition is imperative to the health of both the mother and her infant. For those women who do experience labor during their stay, the use of restraints and shackling should be limited to actual need instead of standard protocol. Women in labor should have the ability to move freely, regardless of their situation. Maternal and fetal health is put at stake when they are put under stressful situations, and shackling only exacerbates the situation. Lastly, childbirth education and support during pregnancy and birth are a great rehabilitation tool which correctional facilities should try to make mandatory. The benefits include healthier inmates both mentally and physically and shorter births which would cut healthcare costs tremendously, considering many incarcerated women are considered high risk. Implementing these policies would help these already vulnerable women and hopefully give them the needed support to change their situations for the better.

Reference List

Amnesty International. (2000). Pregnant and imprisoned in the United States. Birth, 27(4), 266-271.

Anderson, T.L. (2003). Issues in the availability of healthcare for women in prison. In S.F. Sharp & R. Muraskin (Eds.), The incarcerated woman: Rehabilitative programming in women's prisons (pp. 49-60). Upper Saddle River, NJ: Prentice Hall.

Baldwin, K. & Jones, J. (2000) Health issues specific to incarcerated women: Information for state title v programs. Retrieved from http://www.jhsph.edu/research/centers-and-institutes/womens-and-childrens-health-policy-center/publications/prison.pdf

Bell, J. F., Zimmerman, F. J., Cawthon, M. L., Huebner, C. E., Ward, D. H., & Schroeder, C. A. (2004). Jail incarceration and birth outcomes. Journal of Urban Health, 81(4), 630-644.

Clarke, J. G., Herbert, M. R., Rosengard, C., Rose, J. S., DaSilva, K. M., & Stein, M. D. (2006). Reproductive health care and family planning needs among incarcerated women. American Journal of Public Health, 96(5), 834-839.

Codd, H. (2004). Prisoners' families: Issues in law and policy. Amicus Curiae, 55, 2-7.

Committee on Health Care for Underserved Women. (2011). Health care for pregnant and postpartum incarcerated women and adolescent females. Committee Opinion, 511, 1-5.

Hayes, S. L., Mann, M. K., Morgan, F. M., Kelly, M. J., & Weightman, A. L. (2012). Collaboration between local health and local government agencies for health improvement. Cochrane Database of Systemic Reviews, 10, 1-141.

Hotelling, B. A. (2008). Perinatal needs of pregnant, incarcerated women. Journal of Perinatal Education, 17(2), 37-44.

Huang, K., Atlas, R. & Parvez, F. (2012). The significance of breastfeeding to incarcerated pregnant women: An exploratory study. Birth, 39(2), 145-155.

Kitzinger, S. (1997). Sheila kitzinger's letter from Europe: How can we help pregnant women and mothers in prison? Birth, 24(3), 197-198.

Martin, S. L., Rieger, R. H., Kupper, L. L., Meyer, R. E., & Qaqish, B. F. (1997a). The effect of incarceration during pregnancy on birth outcomes. Public Health Reports, 112, 340-346.

Martin, S. L., Kim, H., Kupper, L. L., Meyer, R. E., & Hays, M. (1997b). Is incarceration during pregnancy associated with infant birthweight? American Journal of Public Health, 87(9), 1526-1531.

Minkler, M., Glover Blackwell, A., & Thompson, M., Tamir, H. (2003). Community-based participatory research: Implications for public health funding. American Journal of Public Health, 93(8), 1210-1213.

Walker, J. R., Hilder, L., Levy, M. H., & Sullivan, E. A. (2014). Pregnancy, prison and perinatal outcomes in New South Wales, Australia: a retrospective cohort study using linked health data. BMC Pregnancy and Childbirth, 14(214).

 

About the author

Desiree Robles is a student midwife, attending Midwives College of Utah. She resides in the San Francisco Bay Area and is currently beginning her clinical training with Pearl Yu, LM of Motherborn Midwifery. Desiree also works hard as a volunteer for California Families For Access to Midwives as a member of the social media team.

Albuquerque Has "Poquito de Todo"

Posted by Midwives Alliance on June 23rd, 2015

Albuquerque has "poquito de todo" - a little of everything! We enjoy great mountain views, petroglyphs, hot air balloons, art galleries and many opportunities for cultural learning. There are plenty of things to do in New Mexico no matter where your interests lie.

You might be surprised to learn that New Mexico is a great place to grow lavender, pecans, peanuts, grapes, pinto beans, and more. Of course, we are famous for producing the best chile peppers, a staple in New Mexican dishes.

The MANA Conference will be held at the Hotel Albuquerque at Old Town, right next to colorful Old Town Plaza, a favorite spot to enjoy authentic cuisine and arts. Within walking distance of the hotel are several family oriented museums: Explora, The Museum of Natural History and the Albuquerque Museum.

A short drive from the hotel will take you to the National Hispanic Cultural Center, the Indian Pueblo Cultural Center, and the Albuquerque Bio Park and Zoo.

Albuquerque boasts the world's longest aerial tramway, which runs to the top of the Sandia Mountains. The breathtaking views will give you more reasons to fall in love with New Mexico. If you're brave & into biking, you can also take the chair lift up the mountain and bike down! Beautiful hiking trails are also abundant.

You'll find lots of wineries and craft breweries in the area. There are even bus tours that will do the driving for you! The ABQ trolley will take you on a guided tour where you can see local landmarks, including Breaking Bad filming scenes.

If you're looking for a wonderful day trip, the Jemez Mountains offer gorgeous views, hot springs, canyons, waterfalls, red earth, tall pines and Aspen. Magical Santa Fe, the oldest city in New Mexico and the oldest State Capital in the U.S, is less than an hour away and is home to the Georgia O'Keefe Museum. Just an hour from Santa Fe, in Abiquiu, visit Ghost Ranch.

You can find more info about New Mexico here. For things to do in Albuquerque, visit here.

The New Mexico Midwives are proud to host SHINE MANA#15 in Albuquerque, where we can share with you our history, culture and the amazing support that our community offers midwives.

Please join us for #MANA15 in Albuquerque! Register by clicking the button below.

     SHINE MANA#15

Register for SHINE MANA#15 Now!

About the author

Kelly Camden, LM, CPM, BA, is an Albuquerque-based midwife who is thrilled to serve as the local coordinator of the 2015 MANA Conference. Following her first homebirth 16 years ago, Kelly began attending hospital births as a DONA doula and home births as a midwife's assistant. Later, she became a staff doula at Presbyterian Hospital, where she was recognized for excellent service. Kelly endeavors to empower families through education; she is founder and coordinator of the Albuquerque Birth Network, has taught breastfeeding, prenatal yoga, and childbirth classes and has published articles on pregnancy related topics. Kelly served as Consumer Advisor on the NM Certified Nurse Midwives Advisory Board and Event Coordinator for the ABQ Rally to Improve Birth. Currently, she is a Regional Coordinator for the NM Breastfeeding Task Force. Since 2011, Kelly has practiced as a Licensed and Certified Professional Midwife, offering home and birth center births. She is proud to be a midwife in New Mexico, where a blend of culture, tradition and necessity has led to a continuous history of midwifery care.

Update from the States: Delaware CPM Legislation Passes House and Senate

Posted by Midwives Alliance on June 1st, 2015

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New legislation will make it possible for CPMs to practice in Delaware

House Bill 70 was introduced and passed through both the Delaware House and Senate which will allow for Certified Professional Midwives and Certified Midwives to practice legally in Delaware without a written collaborative agreement beginning June 30, 2016. Since 1984 to present, CPMs needed a physician alliance and written collaborative agreement. This has prevented practice by all but one CPM who currently practices legally and has a written collaborative agreement. That practice currently is limited to serve only the Amish and Mennonite communities per the physician agreement.

Over the past 10 years, there has been continued education and community support for changes to be initiated in the current restrictions toward legal practice of CPMs. Through the many committee meetings with members of the medical community, State Board of Health, and legislators, discussion and education regarding the credentialing process of CPMs has become more clearly understood and accepted. Documents were submitted from numerous states where Certified Professional Midwives are working and valued as a safe option for out-of-hospital birth. Much discussion and work towards safe standards of care has been in process over the past year and now can start to be implemented once the Midwifery Council is designed and in operation. The Midwifery Council will draw up both standards of practice and scope of practice in the state which will then go to the Delaware Board of Medical Practice for approval.

Many thanks to the many members of the medical community, legislators, state board of health and families who were instrumental in helping this goal become realized. Also a special thanks to Shannon Burdeshaw, retired CPM and Karen Webster, CPM for all the time, energy and expertise in assisting the legislative process. Their prior legislative experience in other states served as a great asset to having Delaware join the many other states whose laws recognize and regulate Certified Professional Midwives as primary maternity care providers.

 

About the author

Pat Gallagher, CPM, has been a practicing midwife for 31 years in Delaware. She has been the only CPM legal up to this time due to the need for written collaborative agreement. She has had a physician alliance since 1984 with a practice limited to Amish & Mennonite families per physician back up. 

Pat is a Certified Childbirth Educator (ACHI). She designed and implemented a state wide paramedic refresher class in emergency childbirth and taught a workshop at MANA regional conference on breech & shoulder dystocia. Pat has been active in the legislative process to license CPMs & CMs and on the new legislation.