Home Birth Summit 2014
Russ Fawcett, President of the North Carolina Friends of Midwives, shares his experiences with nuclear power regulation and how consumers deserve trained, credentialed, regulated home birth midwives.
His talk is a part of the 2014 Home Birth Summit.
Russ Fawcett Russ’ pathway to the Summit began as a consumer of midwifery services (both CPM and CNM) in which he had the presence of mind to follow his wife’s leadership as she planned 3 home births. He observed and followed his wife as she worked to become a Certified Professional Midwife and learned to appreciate how important having trained midwives is to women. He is now a leader of one of the largest statewide midwifery advocacy organizations in the U.S., the North Carolina Friends of Midwives. Russ engages the media and the body politic in an effort to cultivate a safe and supportive environment for the women and families that choose midwifery care and the home setting for birth in North Carolina.
Professionally, Russ is a nuclear engineer, a reactor physicist and engineering manager. Russ’ team is charged with the design of the advanced fuel assemblies and reactor cores for the power stations that provide about 7% of U.S. electricity capacity and more internationally. Russ has been engaged in safety analysis for 25 years, an area of expertise that makes him uniquely qualified to evaluate safety, human resource management, and regulatory oversight issues associated with maternity care in both hospital and out-of-hospital settings.
The transcript of Russ Fawcett’s talk is pasted below.
Hi guys. It’s great to see all the faces I know, so … Voices I knew and now I know the face. Before I get started on this, I just need to honor somebody. Her name is Lisa. Quite some time ago she took a 30 something reactor physicist and made him … Pushed him down his pathway to be a father, a husband, an activist … She taught me how to hold a picket sign. She let me watch her become a midwife and serve women and build a community in the state, and lead a state, and have a national voice. I honor her for that. I want to thank all the mothers and midwives for letting me work for you. I appreciate it.
My organization, North Carolina Friends of Midwives, is a consumer organization. We’re comprised of mothers and fathers. The mothers, they’re Marines, they’re farmers, they’re L&D Nurses, they’re Engineers, and they’re Physicians. We have an objective, and it’s a very clear objective and that’s to pass legislation to license, or otherwise unobstruct access, to Certified Professional Midwives because if you do only one thing, if you only have one thing to do. In our view, that’s the thing that you should do.
My organization has engaged the General Assembly. We’ve been on the GOP Party platform and on North Carolina Women United Legislative Agenda. We have an a bunch to pass, both chambers, both bills. We’ve not been successful in achieving that goal. Now as many of you here know, Midwifery Advocacy, doesn’t pay well. It costs me money and it cost me 75% of my vacation days for a long time. I donate that cheerfully because the families are worth it.
My day job is … To understand my role in energy and nuclear energy is like this, if you’re a Nuclear Power Plant Manager and you want to know what the next generation of Nuclear Fuel Assembly looks like and what it means for you, you come talk to me. If you’re the United States Nuclear Regulatory Commission and you want to know how that Fuel Assembly conforms to regulatory requirement designed to protect the public, you come talk to me. If you’re the United States Department of Energy and you want to talk about burning weapons plutonium in a power reactor to get rid of it, which I think is a great idea, you talk to me.
The reason I say that is that the safety debate is the same. It’s the same debate. Out of a low probability, high concentration [inaudible 00:03:53] and how to manage that, and in my world, now we have climate change to deal with. There are two things that make it very different. Number one, as we talked about yesterday, mothers don’t have to ask anybody’s permission to choose a home setting for birth and who attends it. In my world, a nuclear power or utility has to have a license. You have a lot of people who work hard to protect that piece of paper. The second area that’s very different, is that for a long time a lot of people had concerns about nuclear energy and expressed those concerns. I solute their engagement on that, but one of the things … Today, some of those same people are saying we were wrong. We’re more worried about climate change then we are our history of accidents.
One of the things I never heard them say, I never heard them say, I want to shut down the Nuclear Regulatory Commission because I don’t like nuclear power. I never heard them say that and that’s why I can’t understand the dynamic that we have in this conversation, associated with making this safer for mothers.
The Consumer Engagement Group, we put together an evaluation of method, a rubric that I’m going to try and talk from. Just so we can communicate and this will not be a surprise to anybody in the room, of principle importance is of course, client autonomy. We care about that a lot. We have a spectrum of that in the US. We clearly, have not perfected it. Ranging from what I think everybody here understands about particulating risks, options, and pathways. All the way to, you can birth at home but good luck with that.
Access to trained, credentialed, regulated home birth midwives, that’s pretty important for safety and quality. We have examples in US of some terrific states, as well as, some pretty bad states. We’ve talked about environmental conditions and I promote safe and effective transports and the importance of that for safety.
In terms of reimbursement, an important aspect of reimbursement is that women who qualify for Medicaid, we believe this is a terrific option for all women, including those women. Medicaid ought to support those women in having this option.
As well as, legal scope of practice consistent with their training, we know there’s a broad spectrum associated with that. We know in Virginia, licensed midwives don’t get to carry oxygen or anti-hemorrhagic medicines. If we’re concerned about safety, I don’t understand that. Maybe it’s complex.
There’s a lot of similarities between the free standing birth center setting and the home setting. I’m going to tell you in my state, a lot of women are crossing the state lines to have access to the same midwives that we have in our state, going to a birth center in Virginia, Tennessee, and South Carolina, where they can have some access to that.
Inappropriate regulatory oversight. We all want everybody to be successful. We want the midwives to be successful. We care about job performance. That’s what we care about. That’s where the training debate, I think, is an unremarkable conversation. We care about job performance. Job performance, there’s a lot of stuff that influences that. It’s work ethic, commitment to this model of care, training, the environment she works in, all those things. Regulatory oversight principally is a mechanism to protect consumers. In the debate, a license is viewed as authorization to practice by one side of the table. That’s the only thing it’s viewed as. In reality, it’s to ensure that the midwives do a good job. That’s its function.
Oh, what about safety. Okay, so consumer’s care about safety and this is the way I’m wired to think about safety. That is, you’ve got to count everything and you need to put everything on common currency and that means introducing an importance waiting factor. Rolling them all up and we can have all kinds of advanced mathematics and some scholarly conversation about the importance waiting factor. When I hear, home birth is not safe, I just wonder … Okay, let’s talk about your importance waiting factors, probabilities, and all these things.
One thing I forgot to put up, and there are lots of components in the summation. I’ve not seen a lot of literature on it. I call it Iatrogenic Maternal Morbidities because this craziness is killing me.
I want to talk about money. Wasting money kills people. Okay, and there’s a difference in the cost of out of hospital birth, attended by a midwife, as compared to in a hospital setting. We know that. Professor David Anderson from Centre College, put a great big number beside a 10% LOH midwife attended birth. The transfer function to translate dollars into lives, I’m not sure what that is. It might be kind of small, but I know if I throw $100,000,000 at Jenny, and I throw $100,000,000 at Claudia, and I throw $100,000,000 at Paula, I know you’re going to have healthier moms and you’re going to reduce preterm low birth weight babies and we’re going to make those outcomes better.
The safety analysis is pretty complex, if you want to talk about it. I like focusing on the fundamentals. I’m going to skip that because I’m going to run out of time. I want to talk about optimization and practicality. One of the dynamics, I think, having been immersed in this for a while, if I give everybody here a plain sheet of paper and say go design a home birth maternity care model. Go design it. We all like designing things, right? Go do that. You’re going to get a whole bunch of different pieces of paper back. There are going to be some themes on it.
In the United States we have … In this graph, what it is is something first year calculus students see – the difference between a local optimum and a global optimum. They’re worried about getting the numbers right, whether or not they understand that concept. In the United States, we have a local optimum. Out local optimum has licensed and integrated certified professional midwives. It has unobstructed access to nurse midwives. There’s a variety of different things. The thing here is, about half of the United States is pretty close to the best we can do, or have shown that we can do in the United States.
There is a bunch of us, about half of us, who aren’t and it’s pretty bad. I’ll tell you, the thing that is tough for me, there is no justification in my mind, for not driving to the best we know how to do. It’s been done. We know how to do it. We don’t have to invent anything. That’s kind of the energy we bring to the table, is it’s time to get the job done. We know what that looks like. I’m going to let the scholars figure out what the global optimum is and it’s probably going to change over time too. Today, right now, we can dramatically, and overnight, we’re going to make a huge difference in these women’s lives.
If I access North Carolina, I get no points for client autonomy because they don’t have access to midwives. I got no points for access to midwives. I get no points for environmental conditions that promote effective and safe transports. Nurse Midwives or those that attend home birth, they can seek Medicaid reimbursement. I’ll give myself one point for that because otherwise, I’m not going to get any points, at all. I get no points for legal scope because they’re illegal. I get no points for free standing birth centers. I get no points for regulatory oversight because they are unregulated. I’ll tell you folks, I have a hard time wrapping my head around this.
This is really, really important. There are some people in the room who’ve seen the transformation. Somebody who I have a lot of respect for, Ida Darragh. You’ve seen them, haven’t you? This is why I think North Carolina looks like after I pass a couple of pieces of paper. We’ve got about 30 maybe 35 CPMs in the state. Maybe 10 to 13 are practicing now. I’m going to triple the midwife practicing population. We can support about 1,000 women a year. There will be an immediate jump, but all that is, that’s the women who are going out of state. They’re staying home. The women who are birthing at home unattended, who want a midwife, are going to have a midwife. The women who are laboring at home unattended and locking and pushing, they’re going to stay home and have a midwife. I think that’s a good thing. We’ll see what the rates end up being.
Now we can start to put in some infrastructure at that point. It’s pretty hard to produce midwives who walk into an illegal environment. That’s kind of a tough thing to do. I just got to tell you. There will be some complaints. There will be some complaints. That’s the purpose and the role of the regulatory group. Now I can get some quality data, because I think we kind of know how we should measure ourselves. I kind of do, and we can get some data. Our outcomes are not going to be perfect. We can go back to the chart with that mathematics on it and the probabilities, they are what they are. What we can do, we can actually try and do the best job that we can, but we’re not doing that today. I think that’s what I have to say.