July 16, 2008
Volume 10, Issue 15
Midwifery Today E-News
“Insurance”
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When you attend our conference in Eugene, Oregon, in March 2009 you'll be able to choose from a wide array of important subjects. Planned classes include:

  • Massage and Midwifery: Cultural Perspectives in Massage for Childbirth
  • The Impact of Childhood Sexual Abuse on Pregnancy, Labor and Postpartum: Its Effects and Management
  • Beginning Midwifery
  • Reclaiming the Lost art of Twins, Breeches and VBAC
  • Labor Support Comfort Measures
  • Aromatherapy in Birth Work
  • Hemorrhage and Third Stage Difficulties

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In This Week’s Issue:


Quote of the Week

"Faith is to believe what you do not see; the reward of this faith is to see what you believe."

Saint Augustine


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The Art of Midwifery

Getting paid for autonomous midwifery services in the US requires a detailed understanding of how to bill for compensation. Getting paid adequately for these services will allow midwifery to survive, and possibly thrive, in the current health care marketplace. Presently in the US, where the bulk of health care delivery is managed by the insurance industry, many midwives have chosen to attempt to recover some or all of their fees from third-party payers (insurance companies).

Linda Lieberman
Excerpted from "The Business of Midwifery: Billing and the Superbill," Midwifery Today, Issue 78
View table of contents / Order the back issue


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Research to Remember

Routine fetal heart rate (FHR) monitoring is a part of most hospital deliveries, in part to monitor the effect of oxytocin induction on babies. What is lacking is evaluation of excessive stimulation of the uterus that is often an effect of such induction. A small retrospective study of women who were electively induced evaluated the effects of oxytocin-induced uterine hyperstimulation on fetal oxygen saturation and FHR, using electronic fetal monitoring and oxygen saturation sensors.

In all cases, the FHR patterns showed no problem, but when the researchers looked at contraction patterns, they identified oxygen desaturation of the babies occurring "within the first five minutes of excessive uterine activity," and progressing before any problems can be identified by FHR.

The researchers concluded not that oxytocin shouldn't be used routinely in low-risk pregnancies, but that oxytocin use requires "closer surveillance and attention" from medical professionals.

American Journal of Obstetrics and Gynecology 13 Mar 2008; [e-pub ahead of print], reported in Journal Watch Women's Health June 19, 2008


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Questions for the Insurer

When midwives choose to accept insurance reimbursement for services they have provided, they should first determine what the insurance plan will pay toward a homebirth or toward midwifery care in general. I recommend that midwives be impeccable about researching what each client's insurance plan intends to pay toward planned midwifery care for homebirth. A woman with commercial insurance will benefit from calling her insurance company to determine the answers to these questions.

In addition to the client calling to discover what her policy will cover, the midwife can also call the insurer…. Naturally, these calls usually occur on different dates and with different representatives. The provider and the client can then compare notes and identify any discrepancies. As the provider, the midwife will usually have a better understanding of typical care, and she will usually know which Current Procedural Terminology (CPT) codes will be used for maternity services. I encourage each midwife to think of her office as the most reasonable resource for a "clarification call" to the insurer, using information gathered from both [calls].

"Questions for the Insurer" provides a framework of queries aimed at discovering important information about the client's commercial insurance policy which should illuminate how maternity services by the midwife will be compensated. Without such a handout, the client will not know the important questions to ask the insurer, specific to the type of care the midwife will be providing. Only the provider and the provider's associates are well-versed on exactly what will occur within their practice. By creating your own "Questions for the Insurer" specific to your practice and licensing, you will be able to obtain information that can be used to create a financial plan. The financial plan for homebirth is an important contract that you and your client sign. The plan encompasses a reasonable estimate of what the client will be required to pay out-of-pocket prior to the birth.

Editor's Note: To see the "Questions for the Insurer" form for ideas on developing your own, see Linda's article in Midwifery Today, Issue 80.

Linda Lieberman
Excerpted from "The Business of Midwifery: Questions for the Insurer," Midwifery Today, Issue 80
View table of contents / Order the back issue


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Web Site Update

All of the resources listed in the book Survivor Moms Women's Stories of Birthing, Mothering and Healing after Sexual Abuse—and more—are now online here. You may also find links to the full table of contents, Mickey Sperlich's blog, and our Motherbaby Press pressroom from this page.


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Question of the Week

Q: A dear friend of mine was just diagnosed with colon cancer. I'm breastfeeding my 22-month-old and have heard about breast milk helping people with cancer (especially with chemo) but am having a hard time finding info on the subject. I would appreciate any advice or knowledge about cancer patients drinking breast milk. Thanks.

— Eden Robertson


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: If you are breastfeeding and continue to do so throughout pregnancy and the birth, is the next baby deprived of colostrum?

— DMK

A: Absolutely not. The hormonal changes of pregnancy and birth affect milk supply and colostrum production. Typically the pregnant and nursing mother experiences a decrease in milk production sometime during second trimester, and then begins to produce colostrum sometime during third trimester. Colostrum production continues until about the third or fourth day after birth, when frequent nursing by the newborn baby brings in mother's milk. It is important during these first few days for the mother to limit the older nursling's time at the breast, to insure that the newborn receives plenty of colostrum. After that, she need not worry that she won't produce enough milk for both nurslings, provided that the newborn is nursing effectively and frequently, about 10–12 times or more every 24 hours.

Mothers should be aware that colostrum is a natural laxative, and it may cause loose stools in the older nursling. While not in any way harmful to the child, he or she may have difficulty reaching the bathroom in time, if toilet trained.

— Tiana Krenz
La Leche League Leader

A: No, during your pregnancy, your milk production will decrease to the point where all you're making is colostrum. In fact, many older babies will choose to wean at this time; mine didn't, but some do. Once your little one is birthed, your milk won't come in for the usual two to three days. One huge benefit that I experienced while tandem nursing was that when my milk came in again, I didn't get engorged since I had a toddler to help out with the extra milk. For the first couple of months I had so much milk that my toddler stopped eating solids (he wasn't hungry for them) and he became a little chunky. As long as you don't have a tendency toward preterm labor and your nutrition is excellent, tandem nursing can be a very pleasant and rewarding experience.

— Kathryn Balley

A: No, the new baby won't be deprived of colostrum. When a mom nurses through pregnancy her body will still produce colostrum for the new baby. She'll produce milk that's appropriate for the youngest nursling, even if her older nursling is a toddler. I've nursed though pregnancy, even tandem nursed through pregnancy, several times and I have most definitely always produced colostrum for my new babes, much to the delight of my older nursling (usually as old as four to four and a half years old)!

— Cathy

A: No, in fact your first nursling gets extra colostrum! A wise La Leche woman forewarned me that in the middle of my pregnancy, nursing might become tough. She was right! At about five months pregnant, it was all I could do to let my toddler nurse. Intense irritation, both emotional and physical, is how I would describe it. We both wanted to continue, though, so I did the best I could and toughed it out. In about a month, those feelings eased and I was able to nurse him more happily for the remaining months. When the baby was born, she got plenty of colostrum, though my milk came in within about 24 hours. I nursed her often and made sure she nursed first. When she switched to the second side, I would let my toddler join in the fun. He was the happiest little man on earth when my milk came in and he got a full belly, after several months of basically just sips. You should've seen his eyes! He increased his nursings but evened out again within a couple of weeks. (He was about nine months old when I became pregnant, he was 19 months old when his sister was born, and he continued nursing for another three months.) I loved tandem nursing! It was hard, but also a precious time in our lives.

— Brandynn Stanford


Q: In a recent episode of "Baby Story," a mom in labor was offered Ambien, a hypnotic, so she could sleep until she went into hard labor. Does anyone have experience with this or other drugs in its class being used during labor? Does it pass into the baby? Isn't this just going back to the era of twilight sleep (scopolamine a hypnotic and morphine)?

— Anonymous

A: I had a client who at her previous birth was given Ambien in early labor and sent home but since her labor never stopped, she said all it did was make her too dopey to cope with anything and she had to have an epidural (her second baby, after a first non-medicated one). She then went on to have her third at home with no meds.

— Anonymous


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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Think about It

The American Medical Association (AMA) recently introduced a resolution to support ACOG's position against homebirth and to "develop model legislation in support of the concept that the safest setting for labor, delivery and the immediate postpartum period is in a hospital, or birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, the Joint Commission or the American Association of Birth Centers."

Please help send a message to the AMA and ACOG, and to our state and federal legislators, to tell them that we object to these resolutions and we view legislation that would restrict a woman's right to choose a homebirth as a being contrary to scientific evidence and a violation of women's basic human rights.

You can add your voice to this effort at http://www.ipetitions.com/petition/birthathome/


Love birth? You need Midwifery Today magazine!



Feedback

On June 24, the Missouri Supreme Court reversed an earlier court ruling that had struck down a 2007 law allowing midwifery in the state. That law allows certified midwives to provide prenatal, delivery and postpartum care. Several Missouri physicians' groups had filed a lawsuit to prevent the law from going into effect, and had a lower court rule in their favor.

The Supreme Court found that the plaintiffs had no standing to sue—they had no grounds for claiming they would be harmed if the law became effective. Two judges dissented. A proposed legislative change can be expected in the next session, as obstetricians there feel that they are entitled to control and oversee all births in the state.


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