Thursday, July 19, 2012

The Big Push Back

MANA has been hard at work with their "Big Push for Midwives" campaign, aimed at licensing CPMs in every state.  So far they've been successful in 27 states, but not in Michigan.  State Representative Ed McBroom supports licensing for (CPMs) home birth midwives with his House Bill 5070, but what he fails to address in his bill are all the important elements that go along with licensing that would actually help make home birth a safer option than it is at present.  

For example, Representative McBroom forgot to include a sound educational standards for the preparation and training of midwives.  He also missed defining "midwives" as licensed individuals and not anyone who decides to call herself one, defining a scope of practice as being only for low-risk pregnancies, detailing transfer of care protocols, encouraging collaboration with OBs, establishing a balanced board to conduct oversight of the practice, and requiring midwives to report all outcomes.  Not only did he leave these important elements to improving safety out of his bill, he went further to cite NARM as the source who would determine educational standards and hold midwives accountable.  This bill seemed more like a favor to the lay midwives that delivered his four children than one that was meant to really protect women and babies.  

Should home birth midwives be licensed?  Yes.  A licensed midwife should be the only "midwife" allowed to practice by law.  The caveat is that handing incompetent people a license does not improve safety.  Licensing is only one piece of the puzzle.  All of the other pieces have to fall into place if the end result is genuinely aimed at improving safety.  As it turns out, the "Big Push for Midwives" is more complicated than MANA would have us understand.  It's not actually just about licensing midwives. 

Michigan families deserve more...and now they have the chance to support a bill that would actually preserve choice and simultaneously improve safety for women choosing out of hospital birth in our state.  Senator Whitmer introduced Senate Bill 1208 July 18th, 2012 at our state's capitol. 

This bill establishes appropriate, reasonable standards for education and a defined scope of practice for midwives.  It will raise the professional bar for all midwives in Michigan, while preserving a woman’s choice to give birth outside the hospital.  In essence, it will ensure that women choosing out of hospital birth are in fact low risk, and that they are attended by educated, licensed, insured, and accountable midwives.  Here’s what this bill does for you: Senate Bill 1208 Highlights 

Michigan says, "No thank you MANA," we need something more. We deserve regulations that improve safety and allow us the freedom to have an educated, licensed, insured, accountable midwife attend our out of hospital births.  Indeed, this is the Big Push Back.

Thank you, Senator Whitmer, for representing the voice of many women and babies in our state and for working toward safer practices and improved standards for midwives. 

Learn More
Hey Michigan, we need your voices!  Check out our website to learn how you can help and why this bill matters.  You'll find links to the bill, highlights, details about who to contact, what you can do to help, and more!  Now is the time for safer options in birth for Michigan moms and babies.  Help us make a difference.  


22 comments:

  1. OK - I want to make sure I understand - I'm confused.

    Does this create a new category of licensed midwife in Michigan? One that only requires an RN to become licensed as a midwife?

    Or does this require all LMs to be CNMs?

    I wonder if the MI ACNM affiliate will either oppose this bill, or ask for language changes - because the ACNM does not advocate solely for registered nurses as qualified as midwives - but midwives who passed the AMCB exam (for CNMs/CMs).

    I'm confused because it looks like an RN with some unspecified training in midwifery could be licensed in Michigan. Is this the intent? Or am I mis-reading the legalese?

    "LICENSED MIDWIFE" MEANS A REGISTERED NURSE WHO IS LICENSED UNDER THIS PART TO ENGAGE IN THE PRACTICE OF NURSING AS A LICENSED MIDWIFE.

    Not criticizing. Just trying to understand.

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    1. Dear Ex CPM,
      This is an excellent question. I'm doing more homework on my end and making a few phone calls so I can answer your question completely. I didn't want you to think I wasn't responding! I do know that Senator Whitmer's team was meeting with ACNM this week or next about endorsement and feedback. I'm not yet sure what the outcome or advice may have been. More to come...thanks for the question!

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    2. I'm not sure I can clearly answer your question with a yes or no, but I'll try to give as much info as I can. My understanding is that a CM is someone who takes the same exam as CNMs and goes to graduate school, but did not have a nursing undergraduate degree. I also know that this bill proposes to establish a balanced task force devoted to promulgating rules, evaluating accredited programs, determining testing/education standards,and collecting/reporting data on outcomes. The bill does propose to introduce a new term "licensed midwife" to mean someone who has at least a registered nursing degree. My interpretation then is that a CM has much more educational training than a registered nurse and therefore could potentially apply for licensing. I suppose the task force would need to make that "rule". I also think this bill is a beginning, one that will be discussed, revised, and improved upon. The clear issue is that we need to have educational standards for licensing. If CMs are properly prepared and educated, then I see no reason why the task force wouldn't approve them for a state issued license, but I can't speak for them. Perhaps the suggestion of licensing a CM is one you could send to Senator Whitmer, including some info about how they are educated to back it up.

      I know CPMs are up in arms too b/c they don't want to be considered "illegal" to practice in MI. I simply think the inconsistency in how they are prepared and in their standards for practice lead are not enough to be delivering babies. If NARM could get together a consistently high standard for preparation of ALL CPMs, and define a scope of practice then maybe they'd have something...but, NARM doesn't see to want to do that, which leads states to have to determine which standards are appropriate and safest to earn licensing. NARM's standards are not adequate. If CPMs want to be licensed midwives, they have to either a) get NARM to get its act together or b) go to school to be a nurse or c) in you suggestion, have a bahcelor's degree and go to grad school to be a CM.

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    3. I wanted to confirm that I did speak with Senator Whitmer's team yesterday. They said my understanding was correct in thinking that CMs and CNMs would be more than eligible for licensing under this bill. They would need to apply within 180 days, but their educational training would exceed minimum expectations and qualify them to be considered "Licensed Midwives".

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  2. I would love to see a side by side comparison of the House bill (5070) and the Senate bill (1208).

    And I didn't mean to yell with the all caps. I'd copied and pasted directly from the Senate bill. It looks like yelling. I apologize.

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    1. A comparison is a great idea!! I'll work on that today.

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    2. Comparison done. Will post on www.michiganmidwifebill.org today, and as a larger blog post for next week. Great idea. Hoping for lots of feedback when it's up!

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  3. As a physician and research scientist who has watched this issue with interest for a number of years, I can tell you that this piece of legislation is a big mess. It single-handedly eliminates the profession of Nurse-Midwifery in the state of Michigan. Apparently the Senator and her staff are unaware of the fact that Certified Nurse Midwives are long-established health care professionals who provide a broad spectrum of care to women throughout the lifecycle--maternity care, let alone maternity care for home births, represents just a small fraction of the health care services that CNMs provide. CNM services include everything from primary and well woman care, including exams, screenings, and the management and prevention of chronic illnesses and conditions, to menopausal care. Replacing CNMs, who are advanced practice nurses with many years of training, with RNs--who don't even have to have a bachelor's degree, let alone a graduate degree--is very bad public health policy. Women are going to lose access to very critical health care services if this bill passes.

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    1. Dear Dr. PhD,
      I think you misread the bill. It states that a "licensed midwife" would need to have a MINIMUM of a registered nursing degree. A CNM and a CM would more than qualify for that, having gone to graduate school for midwifery. I agree, that CNMs and CMs are vital to offering options and nurturing, high quality care for women. I would not support any bill that proposed only one avenue or eliminated nurse midwives. If any "credential" was in jeopardy, it would be the CPM credential which does not require any school at all, and only recently added the requirement of a high school diploma. This bill would most certainly NOT eliminate nurse midwives. That would be absurd, as they do have far more education and training than an RN. I think setting the bar at a minimum of Registered nurse was meant to be a fair and obtainable way to be a midwife for those (like CPMs) who don't want to go to graduate school, but still need minimum standards for training in order to adequately be prepared to handle the complications of birth.

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  4. The bill strikes through all references to Certified Nurse-Midwives from Michigan statute, thereby eliminating statutory recognition of the profession in the state of Michigan, replacing it with a new profession, Licensed Midwife, which is defined as:

    "LICENSED MIDWIFE" MEANS A REGISTERED NURSE WHO IS LICENSED UNDER THIS PART TO ENGAGE IN THE PRACTICE OF NURSING AS A LICENSED MIDWIFE.

    The bill goes on to clarify that any certified nurse-midwives currently serving on the nursing board have 180 days to become Licensed Midwives, which is the profession that will be represented on the board in place of CNMs. It also eliminates the ability of the board of nursing to issue a specialty certification to CNMs.

    Then the bill limits the scope of practice of nursing as a Licensed Midwife to maternity care:

    "PRACTICE OF NURSING AS A LICENSED MIDWIFE" MEANS THE DELIVERY OF A BABY, NURSING SERVICES PERFORMED IN CONNECTION WITH THE DELIVERY OF A BABY, OR PROVIDING HEALTH CARE RELATED TO PREGNANCY, LABOR, DELIVERY, AND POSTPARTUM CARE OF A MOTHER AND HER INFANT. THE TERM DOES NOT INCLUDE THE PRACTICE OF MEDICINE, AS DEFINED IN SECTION 17001, OR THE PRACTICE OF OSTEOPATHIC MEDICINE AND SURGERY, AS DEFINED IN SECTION 17501.

    So, regardless of whether or not the intent of this bill was to eliminate the profession of Certified Nurse-Midwifery in Michigan and radically limit the scope of all midwives, including those who are nationally certified by the AMCB, that will certainly be the effect should it become law.

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  5. The bill strikes through all references to Certified Nurse-Midwives from Michigan statute, thereby eliminating statutory recognition of the profession in the state of Michigan, replacing it with a new profession, Licensed Midwife, which is defined as:

    "LICENSED MIDWIFE" MEANS A REGISTERED NURSE WHO IS LICENSED UNDER THIS PART TO ENGAGE IN THE PRACTICE OF NURSING AS A LICENSED MIDWIFE.

    The bill goes on to clarify that any certified nurse-midwives currently serving on the nursing board have 180 days to become Licensed Midwives, which is the profession that will be represented on the board in place of CNMs. It also eliminates the ability of the board of nursing to issue a specialty certification to CNMs.

    Then the bill limits the scope of practice of nursing as a Licensed Midwife to maternity care:

    "PRACTICE OF NURSING AS A LICENSED MIDWIFE" MEANS THE DELIVERY OF A BABY, NURSING SERVICES PERFORMED IN CONNECTION WITH THE DELIVERY OF A BABY, OR PROVIDING HEALTH CARE RELATED TO PREGNANCY, LABOR, DELIVERY, AND POSTPARTUM CARE OF A MOTHER AND HER INFANT. THE TERM DOES NOT INCLUDE THE PRACTICE OF MEDICINE, AS DEFINED IN SECTION 17001, OR THE PRACTICE OF OSTEOPATHIC MEDICINE AND SURGERY, AS DEFINED IN SECTION 17501.

    So, regardless of whether or not the intent of this bill was to eliminate the profession of Certified Nurse-Midwifery in Michigan and radically limit the scope of all midwives, including those who are nationally certified by the AMCB, that will certainly be the effect should it become law.

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  6. Dr. PhD,
    I contacted Senator Whitmer's team yesterday and confirmed that a CNM and CM would be more than eligible under this bill to be considered "licensed midwives". They would have 180 days to apply for it, but their educational path and certifications would be upheld. That would mean then that a "licensed midwife in MI" would be a CM, a CNM, or a RN with 50 births in a midwifery apprentice role, and passing a state approved exam. It does exclude the CPM credential at this point, which arguably is not sufficiently consistent training and preparation.

    As for limiting practice of midwives, I read your quote differently. I read it to mean that midwives would not be performing medical procedures such as things like cesareans, vac. extractions, etc. How does the above statement change the scope of practice for a CNM currently practicing? Is it not already standard for they to have boundaries that cross over into practicing medicine? Even a CNM has not gone to medical school, so I suppose that makes sense to me. Defining scope of practice is a good thing if it's done appropriately. More specifics are welcomed. The part of the bill that talks about defining high risk as preterm labor, breech babies, etc is an important part of limiting scope of practice for out of hospital birth providers, and is the standard of care in both Canada and the Netherlands. A responsible midwife understands and appreciates her scope of practice and knows when to risk out. I'd like to know more about how not practicing medicine is changing the way a CNM currently practices.

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    1. It's the state issued license, not national certification, that confers legal practice for health care providers. Otherwise CPMs would be legal to practice in all fifty states. So yes, CNMs and CMs could qualify to become Licensed Midwives under this bill but they would only be permitted to provide the scope of care that their license allows.

      And this bill very clearly limits the scope of practice of LMs to maternity care, thereby making illegal a whole range of services that licensed CNMs are currently authorized to provide, which means no more well woman and primary care, no more care for women and girls, period, that does not take place during the childbearing year. That's a radical limit on the scope of practice for CNMs and will result in loss of access to care for many women should this bill become law.

      Either the Senator's office is unaware of the fact that midwifery care comprises only one part of the many services that CNMs provide to women, or they intend to limit the scope of practice for all midwives, regardless of their credential. CPMs in states where they're licensed have a broader scope of practice than CNMs licensed under this bill would have. Is that really what the Senator wants?

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    2. If this is what the bill does - I can't imagine it would ever pass.

      States usually create a new category of midwife - usually the LM - to license non-nurse midwives - and these LMs have a very limited scope of practice.

      It seems backwards to change the current licensing of CNMs in Michigan - and limit the scope of practice to that of an LM. (If that is what this bill would do.)

      One of the reasons states use NARM (or NACPM or whatever) to regulate LMs/CPMs - is because it's cheaper than to have the state do it. Just something to think about. States aren't too keen on increasing expenditures. And this is one way the proponents of these midwifery bills sell it to state legislators.

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  7. CNMs and CMs in many practice areas obtain additional certification, education, and training to perform many services beyond the core knowledge they graduate with. The can perform circumcisions, vacuum assisted deliveries, surgical 1 st assist at Cesareans, and colposcopies for well woman care. They may be the only contact a woman has with a medical system, and thus midwives provide primary care for many womens' health needs.
    The limited scope of practice as defined in this bill would make it impossible for CNMs and CMs to receive reimbursement from insurance for these services that they already supply. Insurance companies will use the bill as written to limit what they reimburse for because the bill does not specify that the RN Licensed Midwife may provide those services. Women will have a decreased access to care and less continuity of care.
    Nursing is part of the medical profession, midwifery is a separate profession. Although a collegial relationship between midwives and physicians would be the ideal, forcing midwives to have a signed agreement with physicians will result in a de facto ban on birth out of hospital.
    Although I understand your intent is to make OOH birth safer for the families that choose it, the unintended consequence is that you will be making it difficult if not impossible for midwives to meet the limitations in this bill. OOH birth will still occur but it will be illegal by definition and will become more unsafe as it goes underground.

    A board of midwifery, with knowledgeable and experienced midwives would be a much better idea. Licensing midwives, CPMs, CMs, and CNMs, would make them accountable to their peers just as physicians are accountable to their peers on the Board of Medicine, and nurses to the Board of Nursing.

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  8. Comment Submitted By Ex-CPM:

    I'm not familiar with MI statutes and which specific statutes authorize CNMs to practice currently, but bill 1208 appears to weaken the current CNM license in Michigan - replacing CNMs with a new category of midwife requiring only an RN license to practice midwifery.

    Maybe I'm misreading this. But DrPhD1963 is seeing the same thing. I'd like to see a professional legal interpretation of what this law means.

    I'm not arguing with the spirit of the proposed law, but the letter of it.

    This provision in the bill requires amendment - or there will be strong opposition of it from some pretty heavy hitters in the medical field.

    I also think there is a problem in assuming that an AMCB trained CM would qualify - by the letter of this law - to practice. They are not nurses, they do not have a degree in nursing, they do not hold RN licenses - so they would not meet this minimum requirement.

    What is the most effective way of reaching your goal of passing a law in Michigan with safer midwifery standards? Amending Senate bill 1208 or amending House bill 5070?

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    1. I want to respond to Dr. PhD, Ex-CPM, and Linda at one time. I'm not ignoring you by taking so long to respond. Rather, I think you raise VERY valid points here and I'd like to ask questions, do some research, and get back to you with a complete answer. Thanks for your patience and your excellent questions.

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  9. Thank you for creating a forum where we can hash these issues out. I know I'm not the only one here who appreciates the fact that you're welcoming all voices, even if we're raising challenging questions. But I think we're all on the same page when it comes to wanting to craft the best legislation possible.

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  10. No problem Dr. PhD. This conversation needs to happen if any progress can be made. I didn't get answers yet about the certifications of CNMs and limiting their scope of practice. I will say this though, I agree with the points made here, that if the letter or language of this bill is taking away certifications or redefining a CNM, then that specific language should be addressed. I don't think CNMs should have their scope of practice stripped. I do think though, that if a CNM is practicing home birth, she needs to report outcomes, carry insurance, and risk out appropriately, all of which is NOT the case at present. Knowing the intention behind this bill, I cannot believe stripping CNMs of practicing privileges would be what was intended. What was intended is establishing a new minimum standard for education and practice along with parameters for guiding that practice as safely as possible so that home birth can be a more reliable option. CPMs are educated very inconsistently and many practice in very risky ways. "Midwife" means a million and one different things to the consumer and that's simply not safe. A defined scope of practice and a definition for what "midwife" means in terms of educational standards and practice is desperately needed.

    No bill is ever perfect the first time around. That's why our democratic system is in place with both a house and a senate. Ideally checks and balances. I think Senate Bill 1208 puts HB 5070 in check so to speak. It raises the bar and whichever one is brought to a hearing, the negotiations will ensue. It will have to be a thorough discussion and a series of revisions before any bill is voted upon. I don't know that either is perfect, but from my perspective, HB 5070 in its current state is far too weak to do any good at all. That being said, they are redrafting it for the fall, so perhaps they will hear the need for safety parameters and more consistent educational standards. Also from my perspective, SB1208 has much, much more of the elements needed to actually improve safety. Perhaps the RN requirement could be negotiated to include international standards, like Florida, which are still much better than basing those standards on NARM. Perhaps insurance is disclosed on a statewide informed consent document instead of required. I don't know the answer, but I am so grateful the conversation is happening.

    I'd love to know what others think about what would be appropriate educational standards? What would make home birth a safer option? A free for all is not acceptable. Asking our midwives to be educated, licensed, insured, accountable care givers is not asking too much. I wish, instead of arguing about which bill is better, supporters of midwives would ask them to have higher standards for themselves. Then we wouldn't be in this mess at all.

    Thanks guys. More conversation welcome. I'll be posting about this often the next few weeks on the blog.

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  11. "I'd love to know what others think about what would be appropriate educational standards? What would make home birth a safer option?"

    Could you make this a separate blog post? This is a big question - and I'm sure there are many different answers among the readers of this blog.

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  12. I also want to say that I think you guys have made a good point about language here that would directly effect CNMs and their hard earned credentials. This is exactly the kind of constructive feedback that will help make this bill better as it develops. Thank you! Post coming tonight comparing the two bills and asking for more feedback if you're interested!

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  13. I am not as knowledgeable as I'd like to be about the language of the law, but it seems that it would be a simple matter to include language that would state, basically, that CNM's obtaining an LM license would in no way reduce, change or restrict the scope of practice of their CNM, but that obtaining the LM would indicate that they also wish to be held accountable when specifically offering maternity care, even more specifically, when offering out of hospital maternity care. So, conceivably, a CNM could work in a hospital, a clinic, a birth center, or in independent practice offering home, birth center or hospital birth, but that she would be accountable to the Licensing board for LM's as well as the Nursing board? It seems redundant, now that I've written it out. What about conceding that CNM's are already qualified to provide maternity care in any setting? And that the law is intended to ensure that anyone with LESS than a CNM credential would need to be licensed by the new board....

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