Laura Zeidenstein’s Midwifery Manifesto (Excerpt)

             It is the New Year and I have many fears for NYC women, babies, and our midwifery workforce. NYC midwives are a strong minority but our numbers are small and our power is minimal. One problem is that we spread our political priorities too thin. We have no real mechanism to identify and prioritize our focus. Our 400 NYC midwives work hard under adverse circumstances with little infrastructure to support us.

             How do we develop midwifery initiatives and do they actually exist?   A vocal few become the delegates for our city and state and there is no vehicle for input for the rest of us. Even I, in a leadership role, often wonder how a priority has been set. Who is setting our agenda and our legislative priorities?

            The 99% of women in NY who receive their birth care in hospitals deserve legislation to improve emergency prevention and standards as well as legislation that addresses concrete changes to improve justice in birth care. There are positive current trends in legislation that recognize the power of doulas to provide culturally accurate advocacy, review committees on maternal mortality and morbidity, centering pregnancy, and awareness of the damage done when women are disrespected.

            Our first priority in NYC must be to ensure safety for the women and babies that reside here and who we serve. In the Principles for a Successful Professional Life written by Ruth W. Lubic  (J Nurse Midwifery. 1997 Jan-Feb;42(1):53-8.), the first 2 principles state:

• Begin with the needs of the people you serve.
• Take care of all the people of the nation.

            We need to solve the urgent critical issues of unsafe OB care in NYC hospitals. Our message to women needs to be more realistic than, “you are entitled to whatever your heart desires”. In countries that are poor women do not assume they will survive childbirth. It is not about whether you have a tub to labor in or encapsulating dried placenta.

            To be able to decide when and if to be pregnant and having access to affordable safe abortions has lowered maternal mortality and morbidity in every country where it exists. In many richer countries (not the US) women have access to abortion and to safe midwifery care embedded in a system of medical collaboration and support and these countries protect the lives of their people, mothers and babies.

            “In 1970, when New York’s abortion law was passed, the practice of medicine was limited to doctors, and as a result, our outdated law fails to recognize that qualified, licensed health care providers provide early and safe abortion care within their expertise and training.” (Planned Parenthood Empire State Acts, 2019). This was to prevent back alley abortions. Now that Governor Cuomo leads the state with a democratic Assembly and Senate RHA will most likely be passed.  The question remains whether midwives will be included as designated abortion providers. Women in the 1970’s taught ourselves to perform manual vacuum aspiration (MVA ) to each other pre-RvW. Midwives manage early miscarriage and now is the time to add early abortion management.

            In NYC there are 38 hospitals that offer maternity services and we know that the quality of care for women is often substandard. Our focus would be better placed to legislate change in these hospitals than to begin new birth centers that are not supported by our maternity infrastructure. We should not ignore the women who are served by these hospitals.  We also host 30 homebirth practices in NYC and what about legislating for regulations that would ensure safe and equitable transport mechanisms from home to hospital setting?

            How did we decide to put so much energy and focus on the Birth Center legislation to allow a Birth Center to exist without a Medical Director? Who decided that this is a priority for our limited resources in NYC? Where there are a dearth of hospitals in upstate NY how safe is it to have a birth center that cannot provide a safe, fast transport for the 15% who may need a C-section? Are we thinking more about our professional satisfaction than the people who need services? Recently the NY Times article (J. Satow, New York Times: 11/30/18) headlined with a caption “Texas has 70 free-standing birth centers; New York has 3”. Wait a minute! Since when are we praising health care in Texas where less government is involved in protecting people? A state that fights against government regulations, limits access to reproductive health care including abortion for poor people, and provides limited funds for public education. Texas is not a role model.

            Why are NY midwives so upset that birth center regulations are not yet developed? Birth center regs are a BIG deal. I get why it might be taking so long. I worked for many years in out of hospital NYC birth centers including as a founder of one. The regulation requirements though tedious to achieve provided protections for our patients including accessibility, WIC, confirmed medical systems for medical support and transport to a collaborative hospital setting. We want our government to be involved in these decisions unlike in Texas.

            Birth centers are an established alternative maternal care service. They have been proved to be safe when standards are rigorous and collaboration with an extended health care team is established. And there are excellent models of birth centers nationally that collaborate closely with medical centers including the Developing Families Center founded by Ruth Lubic, CNM in 2000. This would be difficult to replicate in a rural setting. Regulations are not our enemy; we need them to ensure safe and appropriate care for mothers and babies. We need regulated arrangements for transfer to hospital and formal collaborative relationships with a medical team.

            How do we set priorities for NYC and NYS?  Who currently sets our agenda and how can we be more transparent to midwives and patients? How can we make sure that midwives are recognized as health care providers who adhere to safety evidence and standards in birth settings, who can be instrumental in assuring adherence to the new NYC standards for respectful care, who will promote reproductive justice and be recognized as licensed health care providers to provide abortions in NYS.