Monday, November 12, 2012

Why Licensing Alone Won't Make Midwifery Safer

A reader recently asked me to explain our experience with licensed midwives, and the implications of legal scope of practice for CNMs in Michigan. 

"What I find curious about Michigan law is that your midwives were licensed certified nurse midwives. What restrictions pertained to their licenses? Were they operating within the legal scope of practice for nurse-midwives when they attended a planned OOH breech birth? If so, what needs to be remedied so Michigan families can be protected from negligence and malpractice of licensed providers."

These are great questions!  First, I should explain that our birth occurred at a freestanding birth center, attended by two Nurse Midwives (CNMs), and two Certified Professional Midwives (CPMs).  Many wonder why we advocate for higher educational standards or licensing when we had CNMs present at our birth.  The answer is that licensing is only one piece of the puzzle in improving safety and outcomes for out-of-hospital birth.  Two of our midwives were licensed, which implies that there are factors that impact safety outside of holding a license.  If this kind of disastrous care can happen with licensed professionals, we need to look more carefully at the practices and expectations of these professionals. 

One of the strongest influences is philosophy, that which a given midwife believes about birth, assessment, and risk.  Does a given midwife believe that birth all costs?  Does she believe that birth is natural, normal, in all cases?  Does she believe that cesarean or intervention is the worst scenario, even more so than death or injury?  Does she believe that some babies aren't meant to live?  Does she believe in assessing risk and risking out?  Does she value assessments to determine risk?  Does she believe that babies don't grow too big? This is difficult to measure, but perhaps has the greatest direct impact on practice.  

Philosophy is not something that can be mandated.  What can be mandated are the assessments and criteria by which we measure risk, who holds a license, and what their minimum standard for education should be.  We can ensure that only low-risk pregnancies are taken on outside the hospital, and that proper assessment is done to evaluate that risk.  This is what many other states and countries are doing, and they're doing it with more qualified, highly trained, professional midwives.

The reader's second question refers to limitations on a CNMs license or scope of practice.  I don't have all the answers to this, but I can do my best to explain what I do know.  There is no law (that I am aware of) that defines a midwife's scope of practice.  The Public Health code simply states that a Nurse Midwife is considered an Advanced Practice Nurse.  It does not detail in any way their scope of practice.  I believe the caveat is that it defers to ACNM as the credentialing body, therefore relying on their standards for scope of practice.  That's the only sense I can make of it at this juncture.  We were told that we couldn't press criminal charges because there were no laws in our state about midwifery.  The state investigation is still ongoing, but the expert witness who reviewed our case did determine that it violated the public health code in some way.  I don't know the specifics yet.  When sanctions have been determined in 2-3 months, by the Attorney General, we can request the documentation that will tell us more.  It's difficult to discern exactly what a CNMs legal "scope of practice" really is in MI because it is not part of MI law directly, at least not that I can find.  (Please comment if I'm misunderstanding this!)

There are no restrictions to out-of-hospital birth practices in MI.  It is legal for a "midwife" to take on any kind or birth, risky or not in our state.  There is no law for what assessments should be done, or guidelines for situations that are simply too risky.  There is no law about what informed consent has to include.  There are no minimum standards for education, meaning anyone can call herself a midwife...even someone who has filed for bankruptcy multiple times over wrongful death, someone who has previously settled out of court for wrongful death, someone who has been convicted of larceny, someone who has had their credentials revoked, and someone who has done time for criminal charges.  Where do these examples come from??  Michigan midwives.  No, not all midwives are felons or have faced civil charges, but too many are.  I don't think anyone on this planet can argue with the fact that this is unacceptable.

Another enormous pitfall of our state leaders is that we collect no reliable data on safety and outcomes of out-of-hospital birth.  This too has to change if we are to effectively analyze safety before we offer up a license, as two dangerous bills (SB 1310 and HB 5070) in MI currently propose.  Legislators have to know who it is they are licensing.  Mothers deserve to know who they are hiring.  The curtain must be pulled back, and the midwives who are practicing responsibly need to take a stand on improving their own profession. 

What has to change to make out-of-hospital birth a safer option?  Our state leaders must first gain awareness, see the need for change, and then implement law that includes ALL of the following components in conjunction with one another:

a) Minimum standards for education (International Standards (which includes some CPMs), CM, or CNM)
b) Mandatory licensing for anyone who calls herself, or advertises a "midwife"
c) Defined scope of practice for midwives
d) Defined assessments and transfer of care protocols for risking out
e) Criteria for informed consent (including disclosure of insurance)
f) Mandatory reporting outcomes

As demonstrated by the death of our son, licensing alone is not enough.  

Note:  We currently have a group of MI midwives working on revisions for a document that would thoroughly explain credentials and scope of practice.  We will share soon! 

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