Aviva Romm on the Impact of Midwifery Care on Lifelong Health

Aviva Romm on the Impact of Midwifery Care on Lifelong Health

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.

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