Monday, September 3, 2012

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. 

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