Lohr Proposes Midwife Legislation

Emmy -- January 17th, 2009

Delegate Matt Lohr has introduced two bills to the House of Delegates that may limit the practices of Certified Professional Midwives. HB 2163 is an amendment to § 54.1-2957.9. This amendment would require midwives to give informed disclosure to their clients about the risk of home delivery.

The second bill, HB 2167, would require the Board of Medicine and the Department of Medical Assistance Services to review regulations and policies to make sure that no reimbursement is made to Certified Professional midwives who provide services in high risk situations, including high-risk home deliveries.

Now there are some issues to consider with these two bills. The first bill appears to be rather redundant. Midwives are already required to give informed disclosure to their clients about the risk of home delivery and some specific pregnancy conditions. They are also required to give written disclosure of their training, experience and the risks of home birth at the start of care.

The second bill will impact low income women and any woman who wants to attempt a natural delivery after having a previous cesarean delivery. Any woman on Medicaid is automatically considered high risk because of her economic status. So with this legislation she would not be able to choose a midwife for her care. It also forces women who have ever had a cesarean delivery to have another regardless of the necessity. Source: VA Birth PAC

122 Responses to “Lohr Proposes Midwife Legislation”

  1. Renee says:

    31%?!? Whoah. There is no way that 1/3 of babies should be born by cutting the mother open.

    “If OBs are so terrified of doing VBACs, then they need to stop doing so many Cesareans. If OBs don’t want VBACs to happen at home, then they need to drastically alter the hospitals they work in so both the staff and the environment is more supportive of natural birth…. Instead of lashing out against home midwives, OBs should focus their energy on improving their own practices.”

    Sounds right to me.

  2. Emmy says:

    See that’s the thing, there’s no shortage of women who actually do need the care of an OB-GYN. Lots of women go to them for non-pregnancy related reasons, some just feel more comfortable with a doctor, and some have risks that require the care of a doctor. They aren’t in danger of going out of business just because midwives exist.

    I believe the problem is, they see c-sections as “safer” because they can control the conditions and feel as though they’ll be sued less. They’d rather not perform a VBAC, but rather than just tell their patients that they don’t want to do it, they tell them it isn’t safe. Then when their patient finds out that they weren’t being honest with them, their patient leaves. Just be upfront about it. Give the patient their options under your care and if they don’t like it, they’ll move on. But there will be plenty more behind them that will still need the OB.

    I think this is more of an ego issue than a medical issue. I had no problem with my OB until delivery. If he had provided better care, and I still had a c-section, I wouldn’t have been upset and might have considered staying with them. Even if I had decided to go another route for my next delivery I may have considered going back to him for care not related to childbirth. Instead, when I need GYN care, I asked to be referred to the GYN’s at my midwife practice.

    Because of the way I was treated, I’ll never recommend the first practice I used to anyone. I’ve sent at least four women to my midwife practice since having my children. I think it speaks volumes about a doctor who will work with a midwife. It means they have checked their ego at the door and realized that they provide different types of care and that’s OK.

  3. Jill says:

    Absolutely, Emmy. There will still be plenty of births for OBs to do, whether they are the high-risk ones, or mothers who don’t feel comfortable with or can’t have a homebirth. Even in countries where homebirth is the norm, around half of the women still birth in the hospital. Homebirth midwives are certainly not going to undermine the entire obstetrical profession. (funny, though, isn’t it, how OBs did that very thing to midwives after the industrial revolution….sad.)

    I think OBs should be more open to working hand in hand with midwives instead of treating them like enemies. How often I’ve heard of a doctor complaining because some “trainwreck” of a homebirth transfer came to him. If OBs were more willing to work as backups for midwives – which is what they SHOULD be, in my opinion, NOT the default! – then there would be no “trainwrecks.” The OB would already be familiar with the client being transferred. He would already have seen her records and know what to do. A transfer is not a homebirth gone wrong…it is simply switching care to a more skilled provider. There are some things that midwives can’t do, and when skills are needed beyond their expertise, they send their clients to someone that can do that for them. Just like a general practictioner would send you to a dermatologist for skin problems, or a podiatrist for foot problems, if it was beyond their scope of practice.

    Though they are rare, I’ve met a few doctors who not only willingly worked with midwives, but strived to emulate their practices. They touch their clients gently, speak to them respectfully, and protect the natural birth process. They are never domineering, rude, or authoritarian. I have seen one particular photo where a doctor was kneeling by the mother’s bed, hands folded, looking up at her in admiration as she labored. It was a beautiful image that brought tears to my eyes. That is what every OB should strive to be. After all, THEY are here to serve US. And like we would in any other relationship, if they betray or mistreat us, we will go elsewhere.

  4. Misty says:

    Mr Lohr,
    I would also like to thank you for your comments. I am happy to know that you are listening to your constituents. Several things that you brought up do have me concerned though.

    You wrote:
    “This procedure is deemed unsafe and risky by the medical association.”

    Based on what evidence?

    Like Jill said before the risk of uterine rupture during a VBAC is less than one percent. The things that increase the risk of rupture include augmenting or inducing labor-both widely done procedures in hospital settings yet NEVER done at home. For example the risk of rupture for a VBAC is 1 in 200, if the labor is augmented with pitocin it increases to 1 in 100, if labor is induced with pitocin the risk is 1 in 43! It appears to me that legislation should be introduce to prevent OB’s from inducing and augmenting labor.

    You also said:
    “but I do have concerns over them attempting very delicate and complex procedures that place mother and baby in dangerous situations.”

    We (midwives) do not place anyone in any situation. Mothers call us. Mothers research for themselves and choose VBAC at home. We do not troll labor and delivery wards looking for c/s moms to advertise to. Most of them are traumatized and angry about their previous experience and after much searching and prayer conclude that homebirth with midwives is the best option for them. I have never heard a midwife talk a women into having her baby at home.

    Who are you trying to protect the mothers and babies from…themselves!?!

    And I also want to comment on the Medicaid thing. I am a medicaid recipient! I paid out of pocket for my home birth although I could have gotten a “free ride” at RMH. I know home birth moms who have made cloth diapers and sold them just to pay the midwife. I know clients that have painted the midwifes home. I know clients who have laid patios bricks. I know homebirthers that traded CSA shares to pay the midwife. I know moms that delayed buying a home and used their down payment to pay the midwife. I know families that used their STIMULUS CHECK from Bush to pay the midwife. I know people that have sold puppies. I know moms that paid $100 a month for more than two years to pay the midwife. The list goes on. When a mom feels safest at home with a midwife she will get what she wants regardless of Medicaid reimbursement.

    Honestly Mr Lohr, this is not a personal attack on you. I hope you do not take my comments as insulting, but this issue is so important to me that I will not stand by and watch these bills go through. I believe that your concern is for mothers and babies. A noble concern indeed, but if you take the time to educate yourself on these issues I guarantee you will discover that the maternity care system in this country is broken and it ain’t midwives that broke it.

    Respectfully,
    Misty Ward

  5. republitarian says:

    Where’s Brent?

  6. republitarian says:

    You know, I’m surprised Dr. Aldrich hasn’t weighed in yet?

    I mean, he was practically Sarah Palin’s doctor during the presidential campaign….

  7. republitarian says:

    Misty, thank you.

  8. Melissa says:

    I just wanted to say thank you to Del. Lohr for sharing your thoughts with us. It’s nice to know there is ongoing conversation and that lawmakers are listening. I appreciate your thoughts.

  9. Dave Briggman says:

    Nice that we have a male Delegate who is also not a physician deciding what OB practices are or are not too risky for midwives…ironically a physician, Dr. Dean Edell, says that most OBs are too quick to perform C-Sections in lieu of vaginal birth.

    Matt, it’s likely time for you to give up your seat…after the explanation you gave me about your vote last year on HB1382/SB788 (something about you not being a lawyer), and now this ridiculous twin pack of legislation…I think you’re way in over your head in this government thing.

  10. republitarian says:

    Just think of all the extra money the medical community has made by cutting all those women that didn’t need to be cut…..

  11. seth says:

    sure would be nice if someone with the credentials to have this conversation felt comfortable weighing in (one of those members of the medical community out to make more money by cutting more women). i haven’t had time to read the whole thread yet, but it sounds like folks have been making some pretty ridiculous assumptions all around the board all the way along. i’ll get better info, but i suspect docs lobbying for this sort of thing has a lot more to do with their reluctance to get handed a f’d up situation for which they are then responsible than it does some avaricious scheme to eliminate competition.

    in any case myron, this wouldn’t be the first time you’re right about something that you probably had no place to say in the first place (or wrong).

  12. seth says:

    (read: if brent’s not comfortable telling you that you’re being an idiot who doesn’t seem to want to have a constructive conversation on this, then i am)

  13. Emmy says:

    Seth, there are a number of qualified people on this thread. But, you are right, no OB-GYN’s or ER personnel have commented weighing in with any horror stories. Either they don’t read the blog, or don’t actually have any to tell.

  14. seth says:

    i just have a hard time when we start throwing out numbers on these things as if we were perfectly qualified to do so.

    i particularly appreciate the perspectives of the midwives and while i don’t disbelieve the points jill made about the risks of vbac vs. subsequent c sections, w/out linking them to some hard facts/studies i am inclined to see them more as talking points than medical facts.

    i’ll speak to some of the ob’s i know. i doubt any will be particularly eager to throw themselves into the fray here but if it’s horror stories you want, i think we can probably come up with at least one.

  15. Emmy says:

    Well, I’m sure there are horror stories, I don’t doubt that. I read about them, and heard about them when making my choice to have a VBAC. I’m not a doctor or a midwife, but there is plenty of information out there to back up what Jill has posted in terms of statistics. If am OB would come on here that would be great. It’s nice to hear from all sides of the issue.

  16. JGFitzgerald says:

    Seth,

    Obviously the technological leaps in the distribution of information, while not creating experts, increase the ability of lay-people to have more informed conversation about these topics. They no longer must be limited to “doctor knows best.” Similarly the same tech leaps make it possible for others to post unsubstantiated skepticism.

  17. republitarian says:

    Industries are famous for collaborating in an attempt to make certain things look like a necessity for more dollars.

    Look at all of the children who have been misdiagnosed for mental illnesses and put on mind altering drugs.

    People think doctors are looking out for them….

  18. seth says:

    :)
    oh joe,
    don’t be a dick. i think that it’s perfectly substantiated to question facts and figures (particularly when there’s no indication of the source or it’s reliability). as i said before though, i’m really not questioning the veracity of what jill or others have said about the risks associated w/ vbac or anything else. i’m wishing that we could take some of the personal element out of this and create an environment where medical professionals would feel comfortable explaining why they would support a bill such as this.

    to me, that means demontrating that we realize it is patently absurd to insinuate things like c-section rates have gone up b/c obstetricians want to make more money and that while we do have unprecendented access to the internet and many other resources, when it comes to our health, still more often than not, the doctor does know best.

  19. seth says:

    myron, i can understand what you’re saying (and it happens everyday w/ circumcisions. are they necessary? no. does insurance cover them? yes. so do they get performed on just about every baby born with a weiner? hell yes!).
    our medical sytstem is, no doubt, incredibly screwed up. doctors being profit driven maniacs who would put your children on unnecessary drugs or gratuitously open up your abdomen isn’t really the problem though.

  20. Emmy says:

    Actually a number of insurance companies no longer cover circumcisions. One of the OB’s who treated me after my c-section actually yelled at me because I wanted my son circumcised. Yet another reason they lost me as a patient.

    I don’t think the majority of doctors are profit driven maniacs as you say, but I do think far too many of them do what is better for them in the long run, than better for their patients. Of, even if their option is better for their patient in their mind, they don’t present all sides. I have some really great doctors, and I have had some that were not great. Giving your patients all the information and letting them make an informed choice is what’s best for everyone.

    If doctors don’t want to do something, that is their right, but be up front with us.

  21. seth says:

    :)
    i’m sorry your doctor yelled at you for wanting to mutilate your son. sounds like he/she could have approached that better.

    ‘but I do think far too many of them do what is better for them in the long run, than better for their patients. Of, even if their option is better for their patient in their mind, they don’t present all sides.’

    i see what you’re saying here, but i’d like to recharacterize it. when you talk about what’s best for them in the long run rather than what’s best for the patient i think you’re missing the mark. what’s best for them is to have a good outcome so they don’t lose their ass in a lawsuit (incidentally, also best for the patient). you can call this selfish, but very few of us have even an inkling of what it’s like to have that kind of responsibility. i agree that it is important for the doctor to present information that allows patients to make informed decisions but ultimately if you’re holding them accountable, it’s their call.

  22. Emmy says:

    Well call it mutilate if you want, but he didn’t change my mind about it and no one else will either ;)

    I don’t know what it is like to be a doctor and run the risk of getting sued. But, in my opinion an unnecessary surgery violates that “do no harm” thing they’re taught in med school.

    I’m not anti-doctor and I hate that people are so quick to sue over anything these days. But their goal at the end of the day should be to provide the best care possible and then they probably won’t have to worry about covering their own rear ends.

  23. Let’s steer the conversation away from circumcision and back on track. I feel like certain commenters aren’t fully disclosing their background(s) here. Seth, what’s your connection to this issue? I’ll admit, I have no background or authority on this issue. Emmy’s had children. So have other commenters. Which commenters know what they’re talking about, and which ones don’t?

    Also, if comments get hung up in moderation: a) we’re not doing it, the filter is. Either there’s something wrong with the filter, or you’re using words that triggered it. And b) we’re not checking the filter 24/7, hitting refresh every five seconds.

  24. seth says:

    i’m not circumcised.

    :)

    seriously though, i think it’s worth noting that there are some unnecessary procedures that we demand while we bang the drum blaming our medical system for the very same thing (gotta make you wonder if the patients aren’t part of the problem).

    i’m not as concerned with people’s connections to the issue (as i said before, it think we need to set the personal stuff aside) as i am with getting a good picture of what’s going on here. one thing that is strikingly absent in this discussion is any reasonable explanation as to why docs would have suported this bill. that’s something i’d like to see.

  25. Emmy says:

    I’d like to see the same Seth, but I’m sorry, this does become a little personal when it is your delegate trying to legislate how you can give birth.

  26. Renee says:

    Overall, regardless of the medical issue, I think we need to see legislation that supports patient desires, especially when it comes to childbirth (which in most cases is not life-threatening to the mother and could technically be done without the presence of an MD unless there’s an emergency).

    Looking at this from an “outside” point of view as a woman that hasn’t had a baby, my gut feeling is that the high rate of C-sections is just plain dangerous. Performing major surgery is obviously much more risky than standard childbirth, and I was shocked to hear that 31% of births in the US now are C-sections, and doctors are seemingly performing them “electively”. Just because the doctor has control over the time and method of birth doesn’t mean it’s safer. Now you have an incision on the uterus and on the skin of the abdomen (risking infection, rupture, reaction to additional anesthesia & medications, etc), plus the risks to the baby.

    I would think the doctor would be much less likely to be sued if the least-risky procedures were performed, and if the patient feels that the doctor has her best interest in mind. If a doctor decides to do a C-section when it’s not necessary, and it’s costing the woman a lot more money (not to mention pain) and on top of that the woman is now upset at the doctor for either not listening to her or not fully explaining the reason for the C-section to her satisfaction, then if anything goes wrong, I would think the patient would be MORE likely to sue.

    Of course, I’m not talking about 2nd birth after C-section here, but I really believe this midwife VBAC issue would be moot if doctors weren’t birthing 1st babies by C-section at an alarmingly high rate, and the legislation should be aimed at that end of the issue.

  27. Renee says:

    It was interesting to me that both high population/weathy counties and rural/poor counties were at the top of this chart when sorted by percent descending:
    http://www.marchofdimes.com/peristats/level1.aspx?reg=51&top=8&stop=86&lev=1&slev=4&obj=18

  28. Jill says:

    Hmph! It won’t let me post my sources list. Maybe if I do them one at a time? That’ll be obnoxious, for sure.

    http://www.childbirth.org/section/risks.html

  29. Jill says:

    Wow, holy jumbled up comments Batman. I’m really sorry everyone. It wasn’t giving me the “your comment is awaiting moderation” notice, and other comments were appearing at the same time, so I mistakenly thought they were lost in cyberspace and kept re-posting them. Sorry for making a mess of this thread!

  30. Emmy says:

    Jill they were stuck in the spam folder because of the number of links. I think I sorted them out!

  31. JGFitzgerald says:

    Interesting that people who ask legitimate questions about campaign contributions are dismissed as conspiracy theorists. Then again, when you have to defend your own integrity, it’s a sign you can’t get anyone else to do so.

  32. Jill says:

    Thanks Emmy! And thanks for deleting the redundant ones. ;)

  33. Misty says:

    Let me guess Emmy, the doctor that yelled at you was Dr Whitten at Harrisonburg OB/GYN AND

    Seth you must be his son, Seth Whitten,

    As for F’d up transports please inform your father that the CPM bill includes an immunity clause for any receiving physician in a trasnport situation.

  34. Jill says:

    Well, there is Brent’s answer, then. I wonder, does being the son of an OB (would that make you an SOB? ;) ) make you as qualified as you demand all of us to be, Seth?

  35. Emmy says:

    As a matter of fact Misty, that’s exactly who it was. He did not perform my c-section though. That may explain Seth’s comments a little better.

    Maybe he can get an OB to come here and talk to us. I think one could lend a lot to the discussion.

  36. Jill says:

    I do hope so, Emmy. The conversation has been pretty one-sided so far. I’d love to see someone offer up a different perspective.

  37. Brooke says:

    What I want to know is how being able to scare up a horror story or two (per Seth’s post) qualifies as justification for banning the procedure for all. Because guess what? There are horror stories that can come from ANY birth situation – home, hospital, vaginal, C-Section, repeat C-section. It has to go beyond a handful of bad outcomes.

    To me, you would have to find evidence of a clear, quantitative and statistically significant risk associated with one procedure over another, before you can really talk about the measures that are being proposed here.

    And I have a big problem with Del. Lohr’s proposing legislation without having first done his homework on what legislation was already out there. How does one defend drafting legislation without properly researched the current requirements and laws? Seriously. You wasted tax payer time and money on something you could have ruled out before beginning. So I’m sorry, I can’t give you kudos for nixing a bill you never should have proposed in the first place. If it was a subject that meant that much to you, you would have researched it before hand, and KNOWN those measures were already in place.

  38. Melody says:

    I’m new to this on-line discussion, but I can see there is a lot of passion on all sides. I haven’t had a chance to read all the great resources, so I’ll just address what I do here in H’burg:

    – I’m a nurse-midwife that ‘catches babies’ at RMH. And just to clarify, women are still having VBAC’s at RMH, thanks to Rep Lohr for correcting this. I am very glad we provide this service to the women in our community, and hope the new legislation would not limit our practice at the hospital. The OB/GYNs that we work with are in the hospital and immediately available despite busy schedules, ‘just in case,’ and many women we work with are thankful for this. We do not induce anyone who has had a previous c-section, since that does increase the chances of uterine rupture, as previously mentioned.

    – As for out-of-hospital births, allow me to share my background. I worked as a nurse at the hospital for several years before returning to school for my Master’s to practice nurse-midwifery. My training, however, was at a free-standing birth center near Washington DC. We carefully screened those who wanted a birth there, and therefore it had an excellent reputation (unfortunately it closed due to financial constraints, but that is a whole other discussion). However, women who wanted VBACs were not eligible for births there because of the requirement for by their credentialing agency, the American Association of Birth Centers (the AABC). The midwives had privileges at a near by hospital, so that is were we attended their VBACs. My understanding is that the AABC deemed VBACs as as not eligible for out-of-hospital setting because of research the following research done by midwives published in the well-established Obstetrics/Gynecology “Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs.” From http://www.birthcenters.org/generations-library/articles.php#results

    – I agree with many of the comments that our system of care for for pregnant and birthing women is broken. Our high c-section rate and it’s impact on future births is a symptom of a larger problem. I think increasing access to midwives are key to amending that system (obviously, I’m biased here). I also think safe, planned home births and births in free-standing birth centers by midwives are part of that solution (see the above site for excellent evidence-based research that shows this). But based on the above research, I don’t think the home or a birth center is the safest place for VBACs.

    I look forward to more thoughtful discussion on this.

  39. Emmy says:

    Thank you so much for sharing your insight Melody and thanks so much for being willing to “catch” for women like me who wanted that type of care.

  40. Jill says:

    Thank you so much, Melody. It’s about time we had a professional weigh in on this. I really appreciate your thoughtful, intelligent comments.

    Unfortunately, it is the nature of many hospitals that I feel undermines a safe VBAC. Routine pitocin augmentation and induction, continous fetal monitoring which prohibits movement to facilitate more productive labor, arbitrary time limits, and lack of access to many natural pain-relief techniques can make a VBAC difficult to accomplish.

    Personally, I know that if I had tried to VBAC at the hospital, I would have been unsuccessful, for a variety of reasons. I know many other VBAC mothers who feel the same way. This is why we sought homebirth. I was well aware of the potential risks, and my midwives and I agreed that we would transport to RMH as soon as it looked like a problem could arise. Thankfully, that was not necessary.

    A home VBAC is not an all-or-nothing thing. If all goes well, the baby is born at home. If problems arise, transport to the hospital occurs where the problems can be addressed. Yes, there are some emergencies that are immediate and catastrophic, but if I may be so bold to say so, some of those would not be any better handled in a hospital. It is up to the VBACing mother to decide if the risk of such a rare emergency arising is better or worse than the risk of recieving interventions in a hospital that could lead to another surgery. But if the environment in hospitals was revamped to be more supportive of VBACs, mothers would not have to make that difficult choice.

    I reiterate that regardless of legislation, women will still seek out-of-hospital births in order to avoid unnecessary surgery. I would much rather have the option of licensed professionals available to these women to attend their births than to see them forced to give birth alone. The fear of Cesarean is that great. I know this personally.

    I would also like to suggest that perhaps it’s time to make the option of homebirth and birth center birth more readily available to first-time mothers. Many of them aren’t even aware of these as possiblities. I believe if more women were staying out of the hospital in the first place, there would not be so many Cesareans, and there would not be the quandary of whether or not to allow VBACs to happen at home. A move towards normalizing out-of-hospital birth and spreading education and awareness of it is called for here.

  41. Jill says:

    I’d also like to briefly touch on the issue of lawsuits as Seth brought up earlier. Yes, Americans are far too sue-happy, to the point of being utterly ridiculous. But, I see lots of cases where the following is the reason for the lawsuit:

    1) The patient is not encouraged to take any active role in her own care, and is essentially told to just let the doctor take charge. As the saying goes, “Play God, and you get blamed for natural disasters.” So when something goes wrong, the patient automatically blames the doctor, since she was led to believe that he would take care of everything. Therefore if things didn’t turn out as planned, it must be his fault, right?

    2) A tragic problem arises, and the only way the family can pay the outrageous hospital bills for treatment of this problem is to sue. Perhaps with a national health care system this would not be a problem, but that’s another discussion altogether.

  42. republitarian says:

    “Perhaps with a national health care system this would not be a problem, but that’s another discussion altogether.”

    That would fix everything!

  43. Melody says:

    Jill,

    Thanks for your personal insight on VBACs. I agree with your comments that we need to provide more choices for women so that we don’t end up with such a high c-section rate in the first place.

  44. Del says:

    This is a very interesting discussion but I am still a little confused. I apologize if any of the following questions were answered earlier but am I correct that Matt Lohr’s revised bill will only restrict Medicaid reimbursement to women who seek VBAC deliveries at home with CPM? Does anyone know how many pregnancies per year in Virginia this will apply to? Someone stated earlier that most CPM aren’t enrolled as Medicaid providers. Is that true? Under the proposed legislation will a mother still be able to attempt a VBAC at home with a midwife as long as she is paying on her own?

  45. Jill says:

    “Under the proposed legislation will a mother still be able to attempt a VBAC at home with a midwife as long as she is paying on her own?”

    I would assume so.

    My concern, though, is that enacting this legislation will further perpetuate a portrayal of VBAC as “too dangerous.” It could also potentially open the door to banning home VBACs entirely.

  46. Lowell says:

    I’d like to ask a bottom line question if I may.

    Given the current economic situation our General Assembly faces, is this an issue which needs the regulation which has been proposed? Are midwives causing a problem in Virginia?

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