Is HB5070 for Safer Midwifery?

With much debate in recent months about proposed legislation that would regulate Michigan midwives, the question of safety remains paramount.  We've written numerous times on this blog about HB 5070 and all of the reasons why it would do more harm than good.  I'd like to address the difference between legislation that will directly protect midwives versus legislation that would directly protect consumers, people, mothers, & families.  (And can I just briefly note, it's not the midwives who are losing their lives in these situations.) 

I have to start then with why non-nurse midwives (CPMs in this case) would want to be licensed through the state in the first place, and further why Representative Ed McBroom would support the notion. For midwives, the key components of having a state issued license is that they can then be reimbursed for medicaid.  For some bizarre reason, they also think this will prevent them from being charged in the criminal court system.  I don't see that connection, because license or not, gross negligence is gross negligence...manslaughter is manslaughter...and practicing medicine without a license is practicing medicine without a license.  A state issued license doesn't protect anyone from criminal charges, whether you believe they are warranted or not.  The third reason non-nurse midwives would like a license is that it would earn them status in some circles, on par with that of holding the same license and practice rights as nurse midwives.  

Let me just point out that nurse midwives have a bachelors degree in nursing and have gone to at least two years of graduate school in midwifery.  They are advanced practice nurses, with extensive clinical training, scope of practice guidelines, and on and on.  Non-nurse midwives however are "educated" in a variety of ways, most not earning a degree of any kind and learning midwifery "apprentice" style.  The exception are Certified Midwives, those who have a bachelors degree in something other than nursing, then attend graduate school for midwifery.  HB 5070 does not address licensing for these midwives to my knowledge.  

What then about Representative McBroom's motivation?  I'm not sure if it's really motivation as much as a lifestyle choice for him.  He comes from a farming family in the rural Upper Peninsula, where there is an extreme shortage of OBs on hand.  His mother had her babies at home, and he and his wife have successfully had their four babies at home, one being breech, and the most recent arrived just this summer.  I think he sees a need for licensed midwives and competent caregivers to serve the women of rural Michigan.  While I agree with the idea, our definition of "competent" differs slightly.  I'll remind readers that two of the four midwives present at our out of hospital birth were nurse midwives, and it still ended in disaster.  This issue is about more than education and licensing.  For that reason, there are several guidelines that need to be added to this bill if the primary goal is to improve safety for those that choose out of hospital birth.  I also think there are many details that need to be addressed and deleted from this bill in the way it is presently written. 

The point of this bill should be to offer licensed, competent, accountable midwifery services for families in MI, with safety at the forefront.  The good news is that Representative McBroom plans to revise his bill for resubmission this fall.  Here are Safer Midwifery for Michigan's suggestions for what would actually preserve choice as to where to have your baby, but would provide appropriate guidelines to help those who do choose out of hospital birth to do so as safely as possible:  (Note, these guidelines are on par with Canada and Europe, but a far cry from the low expectations for midwifery education and practices in the US, particularly MI.) 

1) Licensing:  A license should determine who can use the term "midwife".  Earning a license should define "midwife" as a licensed professional with a specific body of skills and knowledge according to minimum standards for education, and a defined scope of practice. 

2) Minimum Standards for Education: Establishing minimum standards for education is critical to improving consistency in quality of care, and ensuring that those who are advertising themselves as professionals have met a minimum standard for training.  International standards (CNM or a CM as the non-nursing alternative) should be the absolute minimum acceptable education and training for any licensed midwife. 

3) Defined Scope of Practice: Define scope of practice for out of hospital birth, as attending only low-risk births, and further specify the proper steps to screen, evaluate, and risk out any woman whose pregnancy becomes high risk.  The board providing oversight should promulgate risking out criteria and transfer of care protocols, thereby defining "high risk".   

4) Report Outcomes: Mandate that all out of hospital midwives report their outcomes to the state, even in the event of hospital transfer. 

5) Malpractice Insurance:  Require out of hospital midwives to carry medical malpractice insurance, like their in-hospital counterparts.  If they are licensed, it's affordable.  (Or, at the very least, the board providing oversight should draft a state-wide informed consent document that discloses whether or not a midwife carries malpractice insurance, as many other states do.) 

6) Define "Birthing Center": Every "birth center" in MI should be required to be a licensed facility, and responsible for hiring only licensed midwives as defined above.  

7) Establish a "Balanced" Board:  Establish a balanced board within Licensing and Regulatory Affairs that includes majority midwives, OBs, family practice doctors, and citizens to establish practice guidelines, collect data on outcomes, and review cases of questionable care for out of hospital birth is critical in establishing fair and balanced oversight. 

I do think it's possible to write legislation that both, protects midwives and the families they serve.  SB 1208 is the closest we've come to that, despite differences of opinion.  I hope that Representative McBroom can thoughtfully hear the stories of families that have been put in harm's way, and revise his bill thoroughly.  Michigan's families deserve competent, accountable care, no matter what part of MI is their home.  This isn't just about choice, it's about having safe choices.  Legislation must do more than protect midwives, it must protect and serve the people of this great state. 

More mis-information from FOMM: Will Michigan outlaw your midwife?

The Friends of MI Midwives recently posted a lovely piece of fear mongering on their blog entitled, "Will Michigan Outlaw Your Midwife?"  in their response to Senate Bill 1208

Safer Midwifery for Michigan would like to address each point of their position and address the misconceptions: 

SB 1208 will outlaw all non-nurse midwives = FALSE
SB 1208 requires RN training to be eligible for midwifery licensure, but does not require AMCB training as an advance practice nurse and certified nurse midwife for entry into practice. The state is allowed to permit a license to a midwife with an RN license and additional training in midwifery. Please read this carefully, this does not limit licensure exclusively to certified nurse midwives. 

Eliminate access to out-of-hospital birth in most of our state = FALSE
FOMM is saying that since few CNMs practice OOH, this will limit the availability of OOH midwifery practices. The first fault in this reasoning is assuming that this bill limits licensure exclusively to nurse-midwives. This is false. Please see our first point.
    

Elminate the designation of Certified Nurse Midwife and create a new category of licensed midwife = TRUE
This bill aims to license all midwives practicing in the state of Michigan in an attempt to standardize practice guidelines.  Some may have to boost their coursework or skills, but the opportunity is present for all midwives to earn a license.  A few of our blog readers have commented that this has the potential to restrict hospital based CNM practice. This is not the intent of this bill, and I am confident the language will be revised.  
    

New York State licensed midwives under a board of midwifery in 1992. The credential permitted to practice under this law was the AMCB trained CM. And in the past 20 years, some CPMs have become licensed as CMs in New York.  This is another potential revision.
   

Legislate many new restrictions on which births can take place at home = FALSE
Safer Midwifery for Michigan advocates for the safe practice of midwifery. It is in the state’s interest to minimize risk of injury or death during homebirth, especially if state is authorizing license for these professionals, as well as state-funded Medicaid payments to these professionals.  Note – this bill does not criminalize home birth. It restricts who can use the term “midwife” or “licensed midwife” in providing home birth services and outlines a safe practice guidelines for licensed midwifery practice.
   

Eliminate free-standing , independent birth centers by requiring them to work under hospital supervision = FALSE 

Let's look at the SB1208 language regarding birth center licensure:

(B) PRESENT PROOF SATISFACTORY TO THE DEPARTMENT THAT THE

FACILITY HAS A CONTRACTUAL RELATIONSHIP WITH AN OBSTETRICIAN-

GYNECOLOGIST WHO IS LICENSED AS A PHYSICIAN UNDER ARTICLE 15, A

GROUP OF PHYSICIANS LICENSED UNDER ARTICLE 15, OR A HOSPITAL

LICENSED UNDER ARTICLE 17, THAT AGREES TO PROVIDE CONSULTING

SERVICES DURING DELIVERIES.

Providing proof of a relationship with a OB/GYN is not hospital supervision - it is a way for providing accountable, quality assurance to the clients of the birth center.  The Midwives Model of Care includes:

"Identifying and referring women who require obstetrical attention."

This provision is included in SB 1208 to assure that licensed birth centers provide care that is consistent with their own widely-publicized Midwives Model of Care statement.

To everyone supporting HB 5070 - please be informed consumers, and do your research. Don't believe everything you're told by your midwife, or by those purporting to be "friends" of midwives. Do your homework. Read the bills yourself. Take responsibility for your legislation. You are capable of making an informed, autonomous choice, and knowing the facts. Midwives are experts at supporting your individualized, informed decisions. Don't let them tell you what to do.

What We're Seeking: Defined Scope of Practice

I've written before about the number of midwife apprentices who seem to be speaking out about the dangerous practices they have witnessed in home birth.  What concerns me more are those who are too afraid to tell the truth for fear of being ostracized by their own community.  This speaks volumes about the tumultuous dynamic that exists within midwifery.  

Instead of really working to improve practices and keep mothers an babies as safe as possible, a strong undercurrent is working to adhere to misguided practices with purposefully vague guidelines.  What does it mean to "define scope of practice"? It means defining exactly what kinds of births are simply too risky to be taken on outside a hospital, and defining when/how a midwife should recognize that the situation at hand requires the expertise of an obstetrician.  Defined scope of practice helps a midwife assess precisely what is "low-risk" and what is not.  It helps her determine when to take action (ach-em, transfer of care) to ensure the safest circumstances.  Defined scope of practice sets boundaries, not restrictive boundaries, boundaries with a purpose.  Having a defined scope of practice leaves no question marks for the midwife and works to protect the mothers and babies she serves. 

We recently received the following email from a former apprentice regarding informed consent and lacking scope of practice guidelines.  Her words perfectly illustrate the dire need for defining a scope of practice for out of hospital midwives.

"Regarding informed consent...Do I think midwives are incapable of providing evidence-based information?  No.  They are perfectly capable.  But there is no incentive or requirement for them to do so.  Nor are there any professional practice guidelines or professional practice bulletins for CPMs or other out-of-hospital midwives to work from.

• The Royal College of Midwives writes practice guidelines and cites evidence for these practices.

• The ACNM publishes position statements and disseminates research through a peer-reviewed journal.

• Canadian midwives have guidelines for out-hospital-birth and informed consent. And even outline steps to take when mothers refuse a standard of care.

• AWHONN advocates for safer labor and delivery protocols and publishes its own guidelines for FHT monitoring in labor.

"But I have seen nothing even close to this coming from the professional organization(s) that represent CPMs and home birth midwives. 

"Most of the informed consent given by individual midwives are highly skewed toward the midwife's own personal biases and opinions.  They don't have specific professional guidelines to assist them.

"What is (and was) so frustrating to me is no one in OOH midwifery seems to be asking: 'What is the best/safest course of care in certain situations?'

"My first choice would be that midwives would put their heads together, scrutinize the research and evidence, make an HONEST assessment of what types of cases are being attended at home births (high-risk), and come up with (safe!) guidelines supportive of the midwifery model of care.  I don't see this happening."  

So I have to interject here an example in Michigan, of midwives "putting their heads together" for midwives, and regulating midwives with House Bill 5070.  Come on ladies, she said "honest assessment of what would be safe guidelines"!  You're not fooling anyone who really is looking for safer practices in midwifery.  You're just asking the state to hand you a license for your unsafe practices, without really considering what criteria would actually make things safer in home birth.  There are no practice guidelines, in this bill or anywhere else, that have anything to do with evidence-based research for a CPM or out-of-hospital midwives.  Just lots of magical intuition and trust in birth coming from NARM, plus the perks of writing prescriptions for pain control and a board of all midwives to keep your practices hidden.     

"I think the profession (NACPM) should write their own specific guidelines.  And I know I'm asking for moving mountains when I say this.  I think forcing CPMs to act like professionals will either force them to better themselves and their practices - or cause them to become completely fractured. But I think either option is preferable to what exists right now."

For more on this topic:

Home Birth Story: Why women shouldn't have to be their own midwives (coming soon)

Navelgazing Midwife: Succinct Reasons CPMs/DEMs Need to Get Their Act Together

Navelgazing Midwife: CPMs Don't Read This