Tag Archives: Alabama legislature

Alabama Legislators Want “Blood on the Floor”: Especially the Blood of Children and Grandparents


Well. I heard from a very credible source yesterday that our state legislators are not playing chicken with the budget this time. You know, it seems like every year they expect us to display panic and beg them to fund essential programs– it is so predictable it is almost like we have a set script. We get tired of it, but at the same time we think jeez, if we don’t play our assigned role, maybe they will do the bad thing.

This year may be different, if my source is correct. Their plan this time is to go ahead and pass a severely cut budget, which the governor will refuse to sign, and then override him. Then when there is “blood on the floor” (and I quote), they expect us to come screaming to them to pass taxes and re-fund the state. They do not feel they have support from their base, otherwise.

I don’t know. From my perspective, we already have blood on the floor. People in this state have been bleeding all over the floor for a long time, and it hasn’t mattered so far as the budget. The only blood I think the legislators care about is corporate blood and their own, so maybe the point is that business will begin fleeing the state once Medicaid is defunct and all the people in nursing homes have to move in with their families or be dumped on the street.

Getting even a level budget for mental health would not be a win, because there is major blood on the floor with our current budget. Getting the expected cut to Medicaid ($320 million, taking the federal match into account) would make the floor downright slippery. The cuts to doctors will be so sharp, around 40% cut to payments already well below private insurance rates, that I have personally heard several pediatricians say their plan would be to immediately drop Medicaid. Most practices have overhead in the range of 60 to 75%, so that 40% is at least the entire salary of the physician. There will not be enough of us left to see those suddenly doctor-less kids, even if we worked 24-7 without sleep. The 2 Children’s hospitals will close, because they depend on Medicaid money to fund their specialists. And good luck trying to get programs like that rebuilt to their current level of excellence, once they are gone. It takes decades.

Who will be affected first? The elderly in nursing homes. Children (guess they should take more personal responsibility). Because people of color are disproportionately affected by poverty, this is also a racist move. Some advocates are making a case by reminding legislators and voters that middle class elderly are in nursing homes using Medicaid funds, and that there are more poor white kids than black ones. Why should that even be said, as if poor elderly and black kids matter less? Only a racist and classist audience would need to be told such things.

I asked it there is anything at all we can do to stop this disaster, and my source told me we need to call our legislators. I’m going to add that you really need to talk to your neighbors, co-workers, etc and explain what is about to happen. Because legislators have told me previously that although phone and email contacts matter, they also use their in-house polling results, which are secret. They call their base on a regular basis to check in, and I am betting they are getting the no new taxes response from those voters.

If our legislators were ethical, they would be calling those voters not to ask their opinion but to persuade them– they would be pulling out the stops to stop the bleeding. They would stop putting forward bills that they know will cause us to waste tons of money defending federal lawsuits. The fact that they aren’t doing so says a lot.

I remember the last time this type of cut was proposed, and the legislators came up with a Hail Mary to borrow money for Medicaid– I had prominent progressive friends telling me that I was just playing the game by begging for votes to save the program– that I should let things play out, let the blood flow, call their bluff. So it isn’t just conservatives who are the problem. I do not believe an ethical person who understands these are not numbers– they are human beings– would promote such an idea. We all have our preferred ideas of where the funds should come from, and y’all, we do not have strength in numbers to bicker over that right now. If we do, we will surely lose the farm. I can say that a lottery would come too late and is not a solution for the current funding gap, which could begin as early as June. Otherwise, I’d support whatever taxes they are willing to pass, even though I’d prefer to stop corporate subsidies first.

My source says the fed will not likely permit our Medicaid program to be cut so much without responding. We could be taken into some kind of Medicaid custody. But… the kicker is that they can’t MAKE us write a check, so this is different from school integration. They can put key decision-makers in jail, they can withhold federal funding as leverage, but they can’t issue money from the state, raise our taxes for us, etc.

All that said, I would still call your legislators. I would tell them that level funding is not enough for mental health and that it is killing people as we speak, because of waiting times. And if you happen to have a job opportunity out of state, you might want to strongly consider it, especially if you have children. I’m going to stay as long as I can, but I do have a disabled adult family member who depends on both Medicaid and me, so there will be a limit. I don’t know how long my employer will be able to keep me, if well over my entire salary is defunded. Feel free to share all or part of this post if you think it will help.

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Filed under Alabama Legislative Session 2015, Alabama Politics, Children's Issues, Medicaid

Decriminalizing CBD Oil: Let’s Do a Good Deed Together


Complaining about current conditions or worse ones in the pipeline gets tiresome sometimes—nobody really wants to be Debbie Downer. So I’m glad to let you know of a bill in the works for Alabama this year with bipartisan support that could not only actually pass but also truly be a good deed. 

HB 207/ SB 174 would decriminalize the possession of CBD oil from marijuana plants for persons needing it to treat their own medical conditions or their children.

CBD oil, cannabidiol oil, is a natural derivative of marijuana with minimal amounts of THC (the part that makes people high). Although there is not enough THC in the oil to be psychoactive, just the tiny amount present makes the product illegal in our state. Google CBD oil and you’ll pull up rave reviews for treatment of just about everything under the sun. I’m generally suspicious of panaceas—cure-alls, good for what ails you miracle drugs, generally turn out to be fads that get dropped when, surprise, they don’t actually cure it all. I wrote that last line before I found this article with a good description of the endocannabinoid system using almost the same words—by a physician in favor of medical marijuana.

Not all the purported benefits of CBD oil have been seriously studied, but some have. It turns out the research is compelling in animal models of epilepsy. CBD oil has shown strong anti-seizure effects for generalized, partial and temporal lobe epilepsy. We don’t have that level of data for human use, just a few small studies in adults. For children, we do have multiple anecdotal reports of patients with intractable seizures, who didn’t respond to any other treatment, using CBD oil with good results. Some of the stories are enough to make me catch my breath— children with Dravet Syndrome, suffering years of daily prolonged seizures and associated developmental regression, becoming not only completely seizure free or close to it but also showing reversal of their brain damage.

There is one published survey, from Stanford, of 19 parents who tried CBD oil for their children with epilepsy, including Dravet Syndrome. Sixteen of them, 84%, reported fewer seizures, most with 80% reduction or more. The three who didn’t respond did not get worse. The only side effects reported were drowsiness (37%) or fatigue (16%). The authors point out that common side effects of prescription seizure medication—rash (sometimes life-threatening), vomiting, irritability, dizziness, confusion and aggressive behavior did not happen with any of the children.

Animal studies have also not uncovered serious adverse reactions. One paper noted a shift in cytokine production by human cell cultures exposed to CBD, which could be helpful for autoimmune and inflammatory illnesses but might be harmful in chronic infections like HIV. We don’t have good quality clinical data on this question—Cochrane Reviews could not come to a conclusion about long term effects of marijuana or derivatives in HIV outcomes, for good or ill.

The way to find out if CBD will live up to these early reports? More well designed trials, and larger ones.  We need to know if there are side effects that didn’t show up in the smaller groups, the best dosing regimens, and who is most likely to benefit. We need access to oil that will have a reliable concentration of CBD. The FDA has approved sites to study a specific, reliable concentration CBD oil in children, and 7 additional sites will be given IND (Investigational New Drug) approval for compassionate use.

Now I’m at the exciting part. Alabama may be getting one of those compassionate use approvals. I spoke to a respected pediatric neurologist who would be heading the program if done here. She has high hopes that the CBD oil may prove its worth.  She told me it was very important for children to be able to get CBD oil with a known percentage of active ingredient and low THC, because parents had reported inconsistent results from one batch of oil to another with non-standardized products. The problem is that it is illegal in Alabama, standard or not. So parents in the FDA approved program would risk arrest – unless we pass a law to protect them.

The bill doesn’t recommend CBD oil use—both versions are going through their respective Judiciary Committees, not Health. Sure, they leave other ground untouched, like medical marijuana in general or even recreational marijuana. I think it would be inhumane for legal marijuana advocates to ask these children to wait until more comprehensive legislation has a chance. An exhaustive evidence base is not necessary. All we need to do is say CBD oil has no reason to be illegal. I could walk down any drugstore aisle in Alabama, close my eyes, spin around and point my finger, and I’d put money in advance that whatever I’m pointing at would have more known side effects.

When I first spoke to Mike Ball, the House sponsor, he was concerned he might meet opposition from those who are just going to say no to anything remotely related to marijuana. He said it was probably risky to sponsor the bill during an election year, but that after meeting the parents who are begging for help, he had to take the chance. He told me this hill was worth dying on.

I’m a skeptic about politicians, just like panaceas, and I tend to distrust their motives more often than not. Even though Mike and I don’t see certain critical issues the same way, I believe he is an honest man, and I believe he sincerely had his heart touched by these children and their parents. I’m impressed that he was willing to take a political risk for a good deed.

Since we talked, I’m seeing reports that the bill may not meet the opposition he anticipated—that’s good news, and all the more reason for us to pile on. First, we want to be darn sure it passes. Second, we don’t always have to pick only the iffy bills to champion. Sometimes, it might just be good to show an overwhelming support, across partisan lines, for a worthwhile goal. Sometimes, we can all get to be the home team. If you agree with me, please take this opportunity to contact your legislators. No matter what happens in the 2014 midterms or in 2016, we are going to need to find a way to get things done together in Alabama, and maybe it starts with something this simple and sweet.

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Filed under Children's Issues, evidence based medicine

A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 4


Here is part 4 of a series on why I’ve decided to support licensure of certified professional midwives in Alabama.  You might want to read Part 1 for the background, Part 2 for some safety data, and Part 3 about training plus special circumstances of rural/ poor families.

 

Duty of the State

 

After realizing I had used bad data, I still went through a period of not supporting the home birth bills.  I was concerned about midwives accepting high risk clients.  I also worried that without access to the choice of a hospital, poor women in rural counties might be swayed towards home birth disproportionately and that this was not a true “choice” but a default.  I wanted the options for all women in our state to be equally available, and I still do.  I also was concerned at the high degree of animosity I was hearing among the obstetricians.  How would it work to transfer an infant from home to hospital, if the obstetricians could not have civil relationships with the midwives?  I feared this would impair safety for the mothers.

 

I have worked in settings where specialists were rude and verbally abusive to pediatricians—there have been times when I’ve had to take a deep breath before calling for a consult, knowing I was going to receive general nastiness, but doing it anyway for the sake of my patients.  I know of cases where other doctors have let that reluctance delay their call for help.  I’ve had ER doctors call me about patients who clearly needed a specialist level of care and heard them admit they didn’t want to call that doctor because of anticipated rudeness.   I know that bad relationships put patient care at risk.

 

I had a convoluted and admittedly pie in the sky plan worked out in my head.  First we needed to get labor and delivery hospitals in every county and fully license CNMs to work without needing a supervisory physician.  Right now, advanced practice nurses must have what the state calls “collaborative” practice but which is really supervisory practice.  I work in collaboration with other physicians all the time, and most are wonderful, unlike the bad actors I mentioned above. But even if they are higher up the pay scale, they are not my supervisors.  All the CPMs and CNMs I talked to spoke highly of collaborative work and none wanted to practice without those relationships.  What hampers them is this unnecessary supervisory role.  Other states have done away with such.

 

Then I figured the next step would be free standing birthing centers, nearby to hospitals and staffed by CNMs, followed by cautious expansion into home birth.  One CNM faculty member in Georgia set me straight that her trainees were not getting enough training in birthing center or home birth settings to make that workable.  They were going to be mainly comfortable in a hospital environment.  So I switched my mental plan to including CPMs once we got to the birthing center phase. Don’t I sound like Mao, with my five year plan?

 

Anyway, I had what seemed to me a very rational, stepwise progression that would allow physicians to develop good relationships with midwives.  The problem is, as I’m sure you realized—we are just not going to do that in Alabama.  That’s not how we roll.

 

Right now, in our state, we are already having home births.  Many are unattended, and some are attended by “midwives” of uncertain training and credentials.  The CPMs I talked to are horrified.  They are very protective of their certification and license, and they tell me some of the things they hear about would never be permitted by one of their licensees.  They speak of attending our legislative hearings and knowing the stories told about home birth gone wrong are incorrect in critical details—that some of the women involved had been told by multiple CPMs not to deliver at home or vaginally at all, that the wrong practitioner was being slandered, that the mother had refused the advice of the midwife to transfer to the hospital.  They cannot correct these errors because of patient privacy.  They tell me these horror stories are exactly the reason we need to license and regulate CPMs, so women can have access to well-trained and monitored midwives.  Rich women at low risk will find a qualified home birth attendant, out of state.  Those at high risk may make bad decisions at times, just like we all can do.  Poor mothers bear the brunt of inadequate resources.  CPMs would increase their options, not decrease them.  We do not have time to wait until the Shangri-la of hospitals in every county arises.

 

I have an uneasy feeling about licensure in general.  My ideal set-up would be to have almost nothing be illegal in medicine—I would not have a category of crime for practicing medicine without a license.  Instead, I’d rather we just had strong transparency about qualifications.  People should be able to choose if they want a physician, a midwife, or a taxi driver to charge for medical services, but they should know what their chosen provider can do, who has provided the license, and what sort of ongoing monitoring happens.

 

Because we are so license-oriented, however, it seems that the issuing of a license implies that the state has assumed a duty of quality.  I was ok with an adult woman making her own decision about risks and benefits, even if she chose options most of us would consider unsafe.  I was less ok with taking a risk with the baby, especially knowing there were non-low risk home births being done sometimes.  I did not see a right of the state to prevent abortion, but I viewed the status of an infant intended to be born as somewhat different.  It seemed to me we have a collective duty to prevent that infant from being saddled with life-long injury, if being born at home could be riskier in some cases.  So I continued to obsess about the relatively uncommon incidents of high risk home births, instead of focusing on the more common scenario of low risk, good outcome home births.

 

In the end, what nailed it for me and stopped this endless tail-chasing?  Thinking about the women in Alabama who have been imprisoned for being addicted during pregnancy and not aborting, and the women who have been court-ordered to have c-sections against their wishes.  It felt clear to me that the rights of these women were being grossly violated and set aside, not just being put on equal status with the fetus but being utterly overlooked.  We were losing personhood.  We do not stop a person with cancer from refusing treatment, even if that hastens death and even if the cancer is entirely curable.  But we do not allow a pregnant woman to make her own decisions about birth.

 

Any of us who care about women’s rights cannot allow these injustices to continue without protest.  The bright line of the state’s ability to make decisions for a fetus in loco parentis, against the wishes of the mother if she is acting against the future child’s best interest, must be clearly drawn at one moment—when their bodies become separate.  When there is a baby, out of the mother’s body, and not an instant before.   No matter how we define life or personhood, there is just no other way to do it without removing a woman’s personhood and ordinary civil rights.  A pregnant woman, just like the rest of us, should have the right to choose badly or well.  Yes, I realize that can result in burden to the child, just as being raised by smokers puts a child at risk of asthma or being born to parents with sickle cell trait can results in sickle cell anemia and the attendant suffering.  We don’t get to choose our parents.  Unless we are going to start issuing licenses to conceive, the state must limit its scope of power for pregnant women to the same degree as it does for other adults.

 

That does not mean we citizens (the state) have no duty to provide a good environment and safe options for children intended to be born.  I think we can and should agree to assume that duty.  I just don’t think we have the right to make a woman use those resources.  If it becomes apparent that home birth is indisputably safer under certain circumstances, we should not force those women to leave the hospital and deliver at home.

 

Tomorrow:  Part 5 (the end), with my personal birth stories

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Filed under Alabama Legislative Session 2013, women's healthcare

A Woman’s Body is Her Own– Including in Pregnancy and Birth, Part 3


This is the 3rd segment of a series on home birth in Alabama.  Please read the first few paragraphs of part 1 for background.  Part 2 has information on safety data.

 

Training

 

When I first got wind of the CPM bill in 2010, I heard my friends talking about “lay midwives”.  I did not know this label was not only highly inaccurate but highly insulting to the CPMs.  They are most certainly not “lay” midwives, which implies no formal training and sounds sort of like a hobby—“I like to knit and do a little midwifery now and then.”  No matter which side you are on in the debate over licensure, there is no reason to use insulting language.

 

Although the minimal requirements seem just that—minimal—just a number of deliveries does not take into account the reality of the certification.  Seeing those numbers really tripped me up, because I delivered more babies than that in a brief rotation during my 3rd year of medical school, and I know good and well I am not prepared to deliver an infant even in the hospital without backup, certainly not at home.

 

The numbers don’t explain that it would be hard to pass the skills testing without far more experience.  Each CPM must demonstrate specific skills to her preceptor.  (I am going to use the female pronoun in this piece, because around 98% of midwives are female—I mean no disrespect to the male midwives).  She is not even allowed to enter into skills testing until she has been present at enough deliveries to know what she is doing.  I was told by the midwives I spoke to that it took on average 3 to 5 years to acquire enough experience for the certification, usually 100 deliveries at a bare minimum.

 

None of this “see one, do one, teach one” that we have in medical training and which I can personally attest to.  Even though I said above that I am not prepared to deliver an infant in the hospital without backup, I certainly did do it, as a 3rd year student with almost zero weeks of any hands-on patient experience.  I knew the Krebs cycle backwards and forwards, but a live human being in my care was very new.  More than once, it happened that the residents were busy and I was sent in to catch a baby all by myself.  The first time—first time!—I put sutures into a human and not an eggplant, it was an episiotomy repair, after watching the resident do one earlier.  I did not want to do it—I did not feel ready—but no one else was available, and I was instructed that I had to.  Letting the woman lie there with an open wound was not an option.  Thank goodness the nurses were there.

 

Those who compare the CPM training unfavorably to CNM (nurse midwives) should know that the numbers are based on CNM standards at schools around the US, in addition to the job analysis I mentioned earlier.  But the minimum delivery numbers are not reflective of the average actual training.  I wonder if this should be changed to reflect what really happens, mainly for everyone’s peace of mind and for clarity.  However, as it is, without changes, the training is rigorous.

 

CNMs, nurse midwives, receive an RN training plus the advanced practice midwifery. CMs, certified midwives, are the nursing profession’s answer to “direct entry” midwives—it isn’t a commonly used certification.  Interestingly, despite the similarities to a CPM, the CM degree gets touted as an example of a “preferred” qualification by ACOG, the American College of Obstetricians and Gynecologists, with no data to back up their preference.  That tells me they are not just concerned that a midwife should have broad-based RN skills—it is something else, a political problem.  Both CNM’s and CM’s differ from CPMs in that the training must include hospital delivery and does not have to include home delivery.  They read fetal monitor strips, while the CPM’s obtain the same information without the monitor.  They are trained to work with a team, including nurses and physicians, and must know how the hospital environment works.  They provide well-woman care, including contraception, and they can be trained in abortion.  They care for women who have been given induced labor, epidurals and opiate pain medication.  There is no need for a CPM to have these skills to perform home births.

 

Rural Areas and the Poor

 

As I’ve mentioned, we have atrocious infant mortality stats in our rural counties.  Like a third world country.  That’s really what it is, a whole other country, a third world, spread out between and within our cities.

 

Every year, Alabama’s Perinatal Advisory Council publishes a report about the problem.  They lay it out, every sad detail about how we fail our babies.  What gets done?  Nothing much, because they are given no money to do the big jobs.  Read the regional activities for 2012—posters on safe sleep, wellness fairs, and grief support groups for families whose infants have died.  Grief support!  We are doing nothing substantial to increase access to prenatal care or obstetric services in the rural counties—36 of which have NO hospital based labor and delivery units.

 

It might be that if we ever get around to taking the Medicaid Expansion money, some of those funds could go towards building obstetric hospital services.  But a rural doctor doesn’t spring out of the air upon the mention of money.  As I’ve discussed in other posts, a lot more goes into that process, and it won’t happen quickly.

 

We have Mennonites in Cullman County, and they practice home births but cannot legally hire a CPM to assist them.  No matter how nice or fancy a hospital we offered them, they would not likely go deliver a baby there.  We have poor families in the cities and in rural areas who do not trust hospitals and doctors, sometimes because they have been ill-treated and disrespected in those settings.  We have others who are faced with driving hours to a city with a hospital and must consider scheduling a c-section or induction, if they don’t want to risk delivering on the side of the road.

 

Many poor women are uninsured and don’t qualify for Medicaid before becoming pregnant.  They are not used to being part of the healthcare system. Alabama does have a “Plan First” program to provide contraception and tubal ligation, but the program does not include the general medical care needed prior to conception.  It can take awhile to get the paperwork done and get an appointment to start prenatal care, even if there is a doctor available. If women have to travel for those visits, the problem is compounded.

 

When women arrive at some hospitals in labor, if prenatal care is late or they didn’t have it, there is a standing order to obtain a drug test and a social services consult.  Women who have been attending prenatal care put themselves at risk for social services investigation during pregnancy, which can result in DHR records and a plan to either take DHR (Department of Human Resources) custody at birth or require DHR involvement before discharge. Women who are on methadone as treatment for opiate addiction, who should not try to wean methadone during pregnancy if they want a healthy baby, have their babies whisked off to the NICU and are not allowed to breastfeed them at hospitals in my area, despite evidence that this can be done with safety.  On the other hand, if a woman avoids prenatal care and the possible DHR trigger, a social worker consult after delivery may not result in action because she is not already “in the system.”  Whether a woman is using drugs or not, if she knows she will be subjected to special scrutiny for having been poor and pregnant, is it a surprise that she might be reluctant to come for prenatal care?  I have seen DHR investigations triggered solely because the pregnant woman herself had been in the foster care system.

 

Please don’t misunderstand—I am not meaning to badmouth DHR.  They are charged with protecting children in an environment of terribly insufficient personnel and funds.  I am grateful to have a way to help children in my practice who are being actively endangered get to safety.  But there is a bias within the system that results in a higher targeting of poor families and a resulting distrust within those families when they need to interact with medical care.  I do not see any substantial effort being made to change this disconnect.

 

Poor families, rural families with no access to hospitals, and those who have studied the issue and want to deliver at home—these births ARE happening at home, in our state.  Why not make it legal and thus safer, by having a Board of Midwifery to license and provide oversight?

 

That will bring us to tomorrow’s topic:  the duty of the state.

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Filed under Alabama Legislative Session 2013, women's healthcare

A Woman’s Body is Her Own—Including in Pregnancy and Birth. Part 1


This blog has been a long time coming.  Kind of like a three year metaphorical pregnancy, during which I have realized my initial stance on home birth was not only wrong but harmful to related women’s advocacy issues.  I imagine I may not get positive reactions from some colleagues, after joining them in opposition to the home birth legislation—they may feel I have betrayed our common cause.   I may also get annoyance from those in favor of the legislation, for having been so slow to come around.  I am sorry.  It is entirely my fault.  I hope you will forgive me.

 

In short, there is no conclusive evidence that favors hospital vs. home birth in cases of low-risk.  The training of certified professional midwives (CPMs) is rigorous.  There is no imminent likelihood of our state doing anything substantial to address perinatal mortality or expand rural hospital/ prenatal care services.  If the perinatal mortality rates in our poorest counties improved even slightly toward the average rates for home birth, because of prenatal care from midwives, we’d have a reason to celebrate.  Most of all, I do not believe the duty of the state to a child can supersede a pregnant woman’s right to make choices about her own care, safe or not.  In the end, it is simply not our decision to make.

 

I am in favor of establishing a Board of Midwifery in Alabama, according to the framework set out in SB 246 and HB 178 without amendment.   I support the right of a woman to make her own decisions about her body.  I apologize for my error in failing to understand the significance of a position on home birth and in failing to do a good job with my prior reading.   That’s the short and sweet version.  Because the underlying issues are complicated, I’m going to discuss them in parts, over several days.  If you decide to argue differently, you might want to wait and read the whole series first, including the links.

 

A Field Trip

 

After hard re-evaluation and thinking, I decided I would speak in favor of these bills.  For the sake of thoroughness, I also wanted to be able to describe for you what would likely take place in our state if we had certified professional midwives—not just the data but something more descriptive.

 

I contacted Hannah Ellis with the Alabama Birth Coalition, an all volunteer, grassroots organization advocating for healthy mothers and babies.  As part of their intention to increase access to evidence-based maternity care in all settings, they support certified professional midwife licensure in Alabama.  If you would like to sign their petition, as I have done, it is here. Similar efforts have been effective in other states, and I am impressed to have an example of citizens serving as advocates for their own needs—really driving the bus—rather than well known persons trying to steer a movement for others who aren’t even participating.  This is what I’d like to see for single payer—the uninsured and underinsured getting seriously active and insisting on change.

 

Hannah kindly agreed to take me on a field trip to meet some midwives in person.  She took a whole day out of her schedule for this, and I can’t thank her enough.

 

The first midwife I met was Tori Dennis.  We didn’t know right up until the last moment if she would be available—one of her clients could have gone into labor.  Unlike most physicians I know, she is on 24-7 call to the mothers in her care.  She led us into the cozy, simply furnished living room, where she had set up some equipment as if it would be done for a home birth.  There was an inflatable tub (with clean, individual liners) for pain relief in warm water during labor, and she had hurricane lamps lit to show me what it might be like in some of the homes without electricity.  She had oxygen and a resuscitation mask/ ambu-bag ready.  There was a portable tray with instruments set up on a sterile drape, ready to be moved quickly from room to room if needed.

 

In the bedroom, she had more sterile draping, a labor stool, a Swiss ball she said was good for positioning during labor, and 3 bags full of everything you could think of for a home delivery short of a ventilator.  I half expected her to pull one out, by the time she was finished.  Each bag had several plastic sleeves with organized contents—just to pick a few items, she had pitocin in case of hemorrhage, vitamin K shots, antibiotic ointment for the baby’s eyes, cord clamps, suction, a Doppler, and a fetoscope.  The prenatal bag had test kits for group B strep and other infections, blood sugar monitors, everything needed to draw prenatal blood work, vitamins and more.  The post-natal kit had cards for the routine newborn screening state labs, paperwork for registering the home birth and obtaining birth certificates.  That’s just a few of the many supplies—I have not been able to think of anything missing.

 

Tori asked me if the setup was different from what I had expected, and I couldn’t answer—I really did not have any idea at all.  I knew it would be different from Little House on the Prairie, but that’s about as far as I had gotten.  It was very professional and well-thought out, especially the planning for situations both with and without electricity.  She said the midwives had been called on to help in disaster situations, partly because they had experience doing medical work without electric power.

 

We sat down and she told me her story.  She grew up in Pennsylvania, near an Amish community, and came from a background where home birth was normal.  While getting her RN (magna cum laude) from the University of Pennsylvania, she had a “light bulb moment” seeing a 19 year old in the teaching hospital strapped down to the rails in labor and her baby pulled out with forceps by an inexperienced resident.  It seemed barbaric, she said.  The woman didn’t even know she was in a teaching hospital or that there were other ways babies could be born.  This memory stayed with Tori after graduation, when she worked in a neonatal ICU.  At that time, crack cocaine was in its heyday, and pregnancy could be complicated by abruptions of the placenta.  She saw some of the worst things that could happen to disrupt healthy pregnancies and births.

 

Later, as an Army nurse, she assisted with the surgical aspects of women’s reproductive care.  When she finished her military service, she and her husband just wanted some peace and quiet.  They came to Tennessee and bought a farm.  She had no particular plan to become a midwife.  Then she heard about a nearby birthing center.  She initially worked as an RN, with the certified nurse midwife (CNM) there, and then got her certified professional midwife (CPM) training so she could do home births.

 

Tori spoke of mothers with no running water or electricity, with holes in their floor and rats, and people using buckets for toilets.  Mothers who paid her in vegetables and for whom she had to purchase Rho-gam injections out of her own pocket.  She showed me a simple, hand-tied quilt given in payment by an Amish mother—not one of the expensive versions she could have sold.  For these families, she was not just serving as a prenatal care source and a birth attendant but a public health nurse and social worker—she had to teach basic cleanliness practices.  She talked about breastfeeding being even more vital in poor homes, where parents might mix powdered formula from WIC with creek water.

 

She told me about checking on a one month old Amish baby with RSV, who was in distress unrecognized by the family, and convincing them to let her take the baby to the hospital.  She looked frustrated as she talked about the barriers to care in Alabama for families in similar circumstances, such as the Mennonite community.  “We’ve got people going without any care at all,” she said.  “Can we not stop arguing and just get them some help?”

 

She said about half her clients were Amish, poor Amish, not like the ones on television.  Others were middle class or wealthy women, including physicians and lawyers, who had done research and chosen home birth.  Some were past victims of rape or sexual abuse who could not face being examined by male obstetricians or the hospital environment where a male nurse might be on duty.  Many others were just poor and could not get in with an obstetrician.

 

She has a verbal collaborative arrangement with a local obstetrician and she only takes low risk clients.  For her, this means no drugs/ alcohol/ smoking, excellent nutrition (I can’t tell you how many times both CPMs I visited stressed nutrition), no chronic diseases, no first time mothers with breech presentations, no multiples, and VBAC (vaginal birth after c-section) only in very specific cases.  For the higher risk clients, she would not abandon them—instead, she would provide prenatal care in collaboration with the obstetrician and be present as a doula during the birth.  She uses her own car to pick up mothers without transportation for their ob appointments and to the hospital in labor.  She has a low threshold for transfer to the hospital, although her transfer rate is only 2%.  She felt the hospital should be no more than 20 minutes away and would arrange for an alternate home setting for a woman who lived further away.

 

Sadly, the birthing center where she first worked has closed.  CNMs at birthing centers in Tennessee are required to be covered by malpractice insurance, and the rates had become too high.  CPMs are not encumbered so for home births.  Which brings up an important issue.  One of the threatened amendments to Alabama’s legislation would force CPMs to carry malpractice insurance.  This could be similar to the TRAP bills for abortion clinics, something that would prevent CPMs from practicing.  I asked some of my ob friends about it.  They are angry about the perception that a midwife could be involved in a problem delivery, transfer the baby to the hospital, and then walk away without being sued.  They don’t perceive the waiver in the bills to be adequate for their protection, so they want to require midwives to carry insurance also.  I heard some arguments that midwife insurance would protect the families themselves from financial disaster.

 

I disagree.  I would lay part of the blame for our malpractice climate directly on the fact that we are now all heavily insured.  Some patients feel like they are getting insurance money and will sue even if they are not so angry they want to take a doctor’s house or license away.  They believe that money is there to cover their expenses, not necessarily as a punishment.  Civil suits were supposed to replace shooting each other—I’d rather lose my house than get shot, if a patient is that angry.  They weren’t meant to serve as a safety net.  We could do that another way—single payer healthcare would be a start, plus no-fault medical injury compensation funds.  We have messed up in creating this situation.  I see no reason to foist our mistakes on another professional group.

 

I could keep going on about my visit with Tori—I spent a couple of hours talking to her.  Basically it would just come down to her being a saint and wishing we had a whole bunch just like her in Alabama.  I do not know if she is typical of her profession.  I hope she is.

 

The Farm

 

Next we drove to The Farm, an intentional community reminiscent of the 60’s, with a birthing center of international renown.  I met with Carol Nelson, one of the midwives, in their prenatal clinic exam room.  The walls were covered with all sorts of pregnancy and motherhood related art, mixed in with posters about newborn hearing screening and nutrition.

 

Although Carol also had good stories to tell me about home birth, I was most fascinated with her take on the political aspects.  In Tennessee, midwifery was never against the law because it was set apart and not considered medicine.  The midwives and mothers wanted to establish a Board of Midwifery partly to guard against the increasing trend to crack down on midwives in other states and partly to increase the quality of midwifery care from those who were insufficiently trained.  Interestingly, the pediatricians, although they did not actively support the legislation, did not oppose it.  The Tennessee Medical Association did lobby against it hard.  In the end it passed with strong grassroots activism.

 

She told me how the licensure standards for CPMs came about.  It was not a haphazard thing—they had job analysis done, to determine exactly what skills and qualifications were needed.  The National Commission for Certifying Agencies (NCAA), created by the Institute for Credentialing Excellence (ICE) developed the CPM standards.  It is an internationally recognized certificate.  We trust the credentials of a broad range of other health professionals structured by the same agency.  You can read more about the CPM credentials at the North American Registry of Midwives site.  I’m going to talk more about training as well in a later segment of this series.

 

Carol talked about how midwives had helped bring about some of the changes in obstetric care now considered standard, like rooming in with the mother and an increased focus on breastfeeding.  Midwives are participating at the highest levels of policymaking in healthcare, with the World Health Organization, which advocates for increases in the midwife workforce, the Institute of Medicine, and the American Public Health Association (APHA).  APHA is strongly in favor of increased access to good quality out of hospital birth providers, including Certified Professional Midwives.

 

A Tennessee Pediatrician

 

To round things out, I thought I’d better contact a pediatrician in Tennessee who has cared for the infants resulting from home birth.  I called Dr. Rufus Clifford, in Columbia, Tennessee.  Dr. Clifford is on the Board of Midwifery.

 

He had nothing negative to say about the midwives at all and felt they were well accepted in the pediatric community.  He mentioned that they had been quite helpful in providing home visits for newborns for families that couldn’t get to his office soon after a home birth, and that he felt very comfortable with their skills.  When I pressed him to tell me about problems, he paused and said, “Well, they are awfully hard on each other.  When they meet for peer review, they are just awfully hard and don’t cut each other any slack at all.”  I don’t see that as a negative.  Physicians could give each other a little more grief and do better for it.

 

It sounded to me as though the midwives were protective of their credential—they want it to stand for quality care, and they weren’t about to let anyone step out of line and put their profession at risk.

 

That’s it for Part 1, the longest segment of this series.  I hope you will stay tuned tomorrow for Part 2, on safety.

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Filed under Alabama Legislative Session 2013, women's healthcare

Speech at Stop the War on Women Rally II, Huntsville, AL


text of my speech from rally on March 17, 2013, in case you missed us!

It seems like only a few weeks ago we were right here, joining together and ready to fight for a better Alabama.  Same beautiful spring weather.  Last year, we were successful in preventing a great many bad bills from passing—I think we caught Montgomery by surprise.

 

They weren’t expecting us last year.  This year, they were.  Now it seems they believe they can just do whatever they want to do.   They might even think we will give up, when we see how much power they have.  Will we give up?  No!  Because we’ve learned a few things also.  We’ve got power they’ve never even dreamed of.

 

We won’t give up because we know the truth about their agenda.  We won’t give up because we know silence leads to death.  We won’t give up because we know we have a duty to stand together, and that when any one of us is threatened by injustice, all of us are called to speak.

 

Some of our elected leaders say they want to make abortion safer.  The truth is that they want to close down the only remaining women’s health clinics that provide safe and legal abortion.  Because they can’t do that for real safety or legal reasons, they are twisting the law to suit themselves, using whatever arbitrary fire and sedation codes they think will work.  They are lying to the press, implying current clinic physicians are not licensed in our state.  Meanwhile, they are attempting to restrict abortion provider licenses to one community in the state, which has not been done for any other type of medical care.  No other doctors are required to have hospital privileges to practice outpatient medicine.

 

They say they want to protect freedom of religion and conscience, by allowing only one type of religion and conscience to override patient and employee rights.  I hope I don’t shock any of you by saying I’m more concerned with trying to learn how to love my neighbor better in the here and now than I am about the 10 Commandments—but I know the 10 Commandments.  I know them, and not one of them says “Thou shalt force your neighbor to do whatever you want her to do, by lying or intimidating or throwing her in prison.”  There is no 11th Commandment that says to be a bully or to punish or to steal another person’s free will.

 

It’s hard for me to believe they really want to decrease abortion, when at the same time they are throwing women in prison for NOT aborting.  In prison not for possession of drugs, but for the crime of being sick with addiction while pregnant and choosing to give birth to a baby.

 

It’s hard for me to believe they want women to carry a pregnancy to term and at the same time write bills to cut off their food stamps and Medicaid, pregnant or not, if they test positive for drugs.  It’s hard for me to believe they want families to have children at all, when they are steadily dismantling and defunding the services our children need to thrive, like schools and mental healthcare systems.

 

I don’t think any of this is about health, safety, freedom, religion, drugs, life, abortion or even about women.  I say it is all about power.  Women, especially women in poverty, seemed like a convenient target.  There are always people in the world who want to control others, just to show they can.

 

Lots of people are scared.  Scared to lose their jobs if they speak up, and it can happen—some of my friends have lost their jobs.  Scared of death threats.   I’m a pediatrician, and I can tell you some of my doctor friends are frightened.  Some ob-gyn doctors I know fear being killed if they tell the truth about women’s health.  Even some of our leaders are scared, and with good reason.  They’ve seen Alabama take political prisoners.

 

But we who are here today have chosen to be stronger than our fear.

 

I’d be wrong if I told you this next couple of years will be easy.  It won’t.  There are powerful people opposing us.  Things are probably going to get much harder than they are now.  We need to be ready.

 

What I do know is that their kind of power, the kind that depends on lying and twisting the facts and fear and prison is not REAL power—it is false power.  It cannot last.  Never in human history has that sort of power lasted.  It rises, and it falls, always.

 

There’s a different kind of power that DOES last, and we have it right here.  Let’s take just a moment to remember it.  If you have a cold or a health risk and should not hold hands, don’t— you might place your hands over your heart if you like.  You are still connected to the rest of us.  Everyone else, if you want to, reach out and take the hands of your neighbors.  Notice how you are connected to the earth here, connected to our state, connected to each other. You belong here, no matter who you are.  Now lift your hands up high.  Feel how strong we are, together.

 

This is our power, the power that can never be defeated—the power of truth, the power of respect, the power of inclusiveness, the power of connection, the power of community.  When false power has risen and has fallen, we will still be here, standing by each other. We know we are not alone.  The power of our community will prevail.

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Filed under Alabama Legislative Session 2013, women's healthcare

The Dismantling of Justice and Rise of the Medical-Police State


As Alabama continues its slide into financial ruin, many of you may be unaware how severely curtailed some of our necessary state functions already are.  We continue to pile on the tax incentives to corporations without demanding proof of economic effectiveness, and at the same time we add new crimes at a fast clip.  Increased demands on law enforcement and prisons are oddly excused from state requirements to locate funding for the effects of legislation.

 

Drug possession is arrested heavily in Alabama, without regard to whether the possession results from addiction and/or other illnesses, like chronic pain with inadequate treatment or mental illness.  The great majority of arrests have nothing to do with sales—less than 10% in our state.  It is illegal to have the active illness of addiction, and extra illegal to be addicted and black.  If you are a woman and happen to become pregnant while addicted, you can be additionally prosecuted for the “chemical endangerment” of a child.  This is a gender-specific crime—there’s no penalty to the man who contributed to initiating pregnancy within the body of an addicted woman. The only sure-fire way for a woman to avoid those additional charges is to abort.

 

Who will pay the cost of our medical police state?  Just as with sales tax, the burden of funding will fall increasingly on the shoulders of those least able to pay.  We already have multiple “pre-trial diversion” programs in Alabama that allow arrested persons to enter various treatment programs, at their cost, instead of going through the court system, at our cost.  I’ve talked with attorneys who are glad to have these options for their clients, but they admit the programs are mismanaged in many cases and that addicts are placed in them often without regard to likelihood of ability to complete such a program.  Upon failure, they enter prison according to their pre-signed guilty admission and still owe the costs of the diversion program.

 

One lawyer told me he has clients do a dry run of treatment, not supervised by the court, in the time leading up to a decision on diversion.  Because our system has such a backlog, he may have as long as a year to see if his client can succeed.  He will only advise his client to enter formal diversion if the person has done well on the practice effort.  But with low pay for court appointed attorneys, there are unfortunately those with far too heavy a caseload who don’t even meet their clients ahead of time.

 

The quality of the programs is borderline in many areas of the state.  I have a friend whose significant other, a man with bipolar illness and addiction, was sent to one of the “faith-based” programs locally.  When he told the supervisors about his mental illness diagnosis, did they do the correct thing and request psychiatric treatment?  No.  They called in a couple of preachers to pray away the demon of bipolar.

 

Arrest and exorcism as a treatment tool in the war against drugs makes about as much sense as arresting tobacco addicts in the war against cancer.

 

Twelve step groups can be critical for recovery of the whole person, more than just treatment of the addiction itself, and I’ve spoken to many addicts in recovery who say the groups saved their lives.  They tell me there is a tremendous difference between being sober as a “dry drunk” and being in meaningful recovery as part of a community.  But “intention to treat” success rates in twelve step recovery are not substantially better than other methods, meaning that when you take a random group of addicts and send them to walk the twelve steps, it “works if you work it.”  Many addicts will benefit from such groups as an adjunct to additional medical and professional psychological treatment but will fail without ongoing professional help.  There are evidence-based treatments available, including for dual diagnosis of addiction and mental illness, but they cost money—Alabama has none left after the corporate vig.

 

SB 285 is up (again) this year.  This bill would expand the use of pre-trial diversion at the unregulated discretion of the local DA, without need for local legislation or approval.  It specifically allows the use of “certified” faith-based programs.  The administrative fees paid by arrestees would go into the DA’s funds, instead of being used to fund good treatment programs or legitimate fair trial in drug courts.  Although there are provisions to waive the fees for indigent clients, there is no provision against causing a minimally self-supporting person in recovery to become indigent as a consequence of the fees.  I am told by treatment providers this creates a significantly higher risk of relapse during early recovery.  Advocates for those with addiction and mental illness need to vigorously oppose “pay to play” programs that financially burden sick people without giving them a fair trial.

 

We need to reform our entire approach to drugs and addiction.  I’d like to suggest Alabama enter a state-wide Twelve Step program, which can be done in a non-religious way.  Our first step as co-dependents is to admit that all our efforts against drugs that treat addiction as criminal have failed, and the second is to look elsewhere for help.  Testing potential Medicaid and foodstamp recipients for drug use and then cutting off benefits or throwing sick people into prison makes as much sense as emptying an addict’s stash into the toilet or tying a drunk man to the bedposts and hitting him with a skillet.

 

We need to move to the making amends part pretty quickly.  A good start would be to accept the Medicaid Expansion post-haste as well as fully funding addiction and mental health treatment services—good ones, not those involving exorcism. Then we need to seriously consider the benefits of Medicare for All, with full parity for addiction and mental health medical treatment.  Treatment should ideally be provided through evidence-based public programs instead of through faith-based or private programs that rely heavily on funds from high relapse rates.

 

Please contact your legislators and tell them why you are opposed to these bills.  Speaking as an individual citizen and not in representation of any advocacy group, I am dismayed at the public silence of the Alabama Department of Mental Health.  On behalf of their clients, they ought to be all over the news, calling for a moratorium on criminal prosecution of illness.  Their vision statement reads “lifting life’s possibilities through a system of care and support that is consumer driven, evidence-based, recovery focused, outcome oriented and easily accessible, with a life in the community for everyone.” DMH, where are you? Will you not speak up?

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Filed under addiction, Alabama Legislative Session 2013, evidence based medicine