Dear Friends:
    My midwife was with me through many miscarriages and a 43+week gestation
baby. She saved me from a cesarean section and caught my daughter. She helped
my older daughter through that first well-woman check-up, including a pap
smear. She helped me through a breast lump scare. I am only one of thousands she
has served.
    I am posting this, her letter, because it clearly documents what is going
wrong with midwifery care in the USA now. It is heartbreaking.
Her letter describes a juggernaut which is itself the outgrowth of toxic
capitalism.

This is all important for us as well, because breastfeeding becomes nothing
but a series of hurdles in technologically-driven birth. When women have lost
not only their choice, but their knowledge of any options, what future is there
for spontaneous, undisturbed birth and easy breastfeeding?

Subject: FW: Valley Birthplace forced to suspend services

On August 20, 2004 at 5:00pm, the midwives at Valley Birthplace & Woman Care
were forced to temporarily suspend services at the birth center for births and
office visits until a new consulting physician or Director of Medical Affairs
can be found.

The administrators at _____ Hospital decided that the hospital owned
physician practices (they own all of the physicians on staff) are no longer allowed to
have agreements with entities they don't own, such as ours.  And, as you all
know, our state regulations do not allow us to practice without a
collaborative agreement. I was told this decision is an attempt to reduce their liability
exposure and it is obviously a trickle down effect of the current malpractice
crisis.

The hospital's stance is that privileges will be available to us when we can
show them a letter of agreement with a collaborative physician. I was invited
to recruit a physician in private practice not currently on staff to obtain
privileges at ____Hospital  and serve our practice and the birth center in this
capacity; however, this was an option I could not possibly accept.

Obstetricians can't afford to be in private practice because of their
exorbitantly high malpractice insurance premiums so they work for hospitals.  So how
could I come up with the $60,000 to $150,000 premium?  And that's for ONE
doctor.  Do you know anyone who wants to cover midwives 24/7? We haven't even
considered their salary. And why would anyone be attracted to come to the
epicenter of the malpractice crisis in the first place? Doctors are not coming to
Philadelphia, they are leaving Philadelphia.

Doctors I tried to recruit were overwhelmed with their own practice volume
resulting from so many of their colleagues closing their practices and couldn't
see taking on one more responsibility.  Bringing more deliveries to the
hospital is no longer a bargaining chip; they're all bursting at the seams.  Other's
practices were owned by their hospital had the same restrictions in forming
outside agreements.

During the last few months, I met with my consulting physician numerous times
to discuss alternative options. We considered joining his practice, but
midwives don't generate enough revenue to satisfy the hospital system.  After all,
we're paid at 65% of the physician's rate and we see fewer patients in a given
hour than the physicians.  Then there's all the time we spend attending labor
and we don't generate billable services because we don't do surgery, we avoid
unnecessary interventions and have fewer admissions to the NICU.  Midwives
are just not as productive as physicians and money is the bottom line. (Remember
when we used these same arguments on 3rd party payers to show that we were
cost effective?)

The alternative we settled on was that our consulting physician would
continue in his role as Physician Director of Medical Affairs at the birth center if
we agreed to the following: eliminate the option of planned hospital births,
only register clients who meet birth center risk criteria, admit all transfers
from the birth center to MD service (i.e. they bill).  Since we lost the
ability to really practice midwifery in the hospital (with all the fear of
liability based restrictions) a long time ago, I accepted, and actually looked forward
to the idea of doing only birth center births and the chance to practice true
midwifery again, even though this meant cutting 50% of my practice.

So over the last few months, believing this plan was legitimate, we sadly
said goodbye to some clients planning hospital births and I feared that our
registrations would drop too low to afford to stay in business. Happily, many
clients changed their plans and decided to give birth at the birth center. Our
birth center registrations had never been higher.  Then at the end of last week,
word came from the VP of Physician Services and later the COO that this
arrangement would not be permitted under my consulting physician's contract. I was
left with 2 business days to find a new arrangement and was unsuccessful. I
contacted my attorney, who was able to get a 3 day extension, but that was not
enough.  She offered to file an injunction, but the $15,000 fee just to get it
started with no guarantee of success was prohibitive. So we had to close.
Hopefully, it's temporary.

Things need to change.  What happened to us is a global problem and it will
happen to you too unless things change.  Our clients are our catalysts, but
they don't know how hard it has always been to practice midwifery. We have
protected them from that reality by being excellent crisis managers.we are strong
and we survive.  But instead of surviving from one crisis to another, I would
like to see us flourish as a profession.  To do this, we have to tell the truth
to our clients.  We have to talk to them about the issues and take the time to
explain to them that the services they want and have enjoyed with us will not
be available to them or to their daughters and sons.  They need to get
politically active.  Many don't know that the problems caused by frivolous law suits
are affecting their access to midwives and their freedom of choice in
childbirth.  Help them understand the connection.

We need our autonomy.in the true sense of the word just like other specialist
providers.  We do not need collaborative agreements or even signed off
practice protocols.  We do not need to pay money out of our own pockets to refer our
clients to a higher level of care.  A Cardiologist does not need to have a
written agreement with or pay a fee to a CT Surgeon when his patient needs a
stent.  They simple get a written report with a "thank you for allowing me to
participate in the care of your lovely patient".  It is this restraint of my
trade that put me out of 22 years in business.  Things need to change or midwifery
will die.

Like I said  yesterday, my eyes are blurry from sharing tears with all my
clients and I need some time to think and pray.  I guess I've begun to grieve
already.  My heart hurts and I can't believe this is happening.   Transition is
always difficult, but with your support, I know I'll get through this as long
as I keep breathing.  If you made it this far, thanks for listening.



Barbara d'Amato, CNM

Owner and Director

Valley Birthplace & Woman Care
sadly,
Nikki Lee RN, MS, Mother of 2, IBCLC, CCE, CIMI
Maternal-Child Adjunct Faculty Union Institute and University
Film Reviews Editor, Journal of Human Lactation
Support the WHO Code and the Mother-Friendly Childbirth Initiative

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