What We're Seeking: Standards for Education

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the need for consistent, high standards in the education of all midwives.   

Think about your profession. Are you a plumber? A teacher? A lawyer? Consider the range of qualities among your colleagues.

If you are going to hire a lawyer, do you want to hire a mediocre lawyer who was trained at a questionable school?  A teacher who earned her degree online, but has little experience with children?  Do you want the least qualified economist to make policy for the country? No . . . you want the best person you can find.

That is why there has to be a bar, a high bar by which all members of a given profession must be measured as a minimum standard of education.  In the case of emergency/specialized care, there has to be a significant amount of intensive clinical training and consistently current educational standards to ensure these professionals are adequately prepared when lives are at stake. 

With no standards for education, the danger is that there is no bar.  This is precisely the case for midwives in MI today.  There is a vast spectrum in the training of midwives that spans those that have no formal education whatsoever (literally learning through mail order and watching you tube videos) to those who have advance practice nursing degrees...and everything in between.  Not only is it nearly impossible to sort the mediocre from the highly qualified, it's down right dangerous to consider that the person calling herself "midwife" could lack the essential skills necessary to keep women and babies safe during birth.  Hiring a competent midwife is confounding to the consumer when there is no minimum standard for the education, training, and skills she possesses.   

When we hired a midwife we made too many dangerous assumptions, one being that anyone who called herself a midwife was educated and competent, a trained expert in birth.  While this might be true for some Michigan midwives, it certainly is NOT true for all of them.  How can consumers know with certainty that who they are hiring has at least had sound educational training behind them when there are no standards for how midwives earn their title or even standards for how they practice?  

Further complicating things is the fact that the qualities that seem so important to those hiring midwives actually end up being those that matter the least.  Many women want their midwife to be warm, friendly, personable, compassionate - and most are.  Well, those things matter if you are a Kindergarten teacher, or if you work at a coffee shop. But when you board your plane, do you peek into the cockpit and think, "Wow, I hope he is friendly!" No. You look at the pilot and think to yourself, "I hope he knows how to fly this plane and keep all of us safe."  

Do pregnant women deserve nurturing and compassion?  Sure, but not at the sacrifice of safety and the utmost competence.  These are women and babies we're talking about here, life and potentially deadly events.  How can MI allow anyone to call herself a midwife with no standards for education or training?    

Safer Midwifery for Michigan is advocating for clearly defined, higher standards for the education of ALL midwives. 

What We're Seeking: Defining "Birth Center"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines more closely, the current state of "birth centers" in Michigan and further indicates improvements Michigan families deserve.

Freestanding birth centers are not currently regulated in any way in the state of Michigan.  I could literally wake up tomorrow, call myself a midwife, and open a "freestanding birth center" in my garage according to current MI laws.  "There are 215 freestanding birth centers in the United States, with more in development. The number of birth centers has increased more than 20% over the past 5 years; they are regulated in 41 states." (American Association of Birth Centers.  http://www.birthcenters.org.  Accessed March 30, 2012)  

What is a birth center?  

The term "birth center" refers to a facility that specifically is designed around birth.  Birth centers are generally more in tune with supporting and nurturing a woman in labor.  In Michigan, we have birth centers that are attached to or affiliated with hospitals.  We also have "freestanding birth centers," which is an entirely different model and a body of absent regulations.

 

What is a" freestanding" birth center?

 A freestanding birth center is one that is not affiliated with a hospital or a physician.  The birth center may have a consulting physician, but this relationship is as your midwife determines a consultation is necessary.  It is not in a capacity of oversight.  Freestanding birth centers are not required by MI law to be licensed as a facility or insured, nor are there any regulations that specify when you should consult a physician.    

How is a birth center different from a hospital?  

A birth center's mission is to support and perceive birth as natural and normal first.  The staff is trained to support women and create an environment that embodies this mission.  You may find options in a birth center that more traditional hospitals don't offer, such as birthing balls, water birth, birthing stools, etc.  A freestanding birth center goes further to offer things like homeopathy, placenta encapsulation, and the freedom to birth without any rules or regulations in place.

Freestanding birth centers do not have emergency medical equipment beyond oxygen.  They cannot intubate or give medications that would be used in a resuscitation circumstance. They do not use Electronic Fetal Heart Monitoring, instead using intermittent Doppler assessments.  Midwives working at a freestanding birth center may or may not be licensed as individual, may or may not carry insurance, and may or may not be trained in NRP (Neonatal Resuscitation Program).  The bottom line is that in the event of an emergency, they are under equipped for life saving measures. 

     

Who works in a birth center?

In a hospital affiliated birth center, you care is primarily with a licensed, nurse midwife.  If at any time during your pregnancy or labor complications arise, your care would shift to that of an obstetrician at the same birth center or hospital.  

In a freestanding birth center, midwives, doulas and other staff run the facility.  Some may be licensed nurse midwives, others certified professional midwives (no license), and other apprentices or lay midwives (also not licensed).  Often times midwives in a freestanding birth center have a physician they will work with to refer clients they determine to have complications.  (Bear in mind that this determination of need is solely at their discretion as there are no regulations.) 

Are birth centers safe?    

This is subject to opinion and definition of "safety".  It is our belief that a birth center affiliated with a hospital is the safest alternative to a hospital birth.  Medical technology and staff are immediately available and they have high standards for education, scope of practice, and review of outcomes.  It seems to be the best collaboration at present, between out of hospital birth and traditional maternity care.  As you will read in many of our other posts, without defined regulations, standards for education, defined scope of practice, and without reporting outcomes, freestanding birth centers vary widely in ethical practices.  This poses great risk in terms of safety.  It's difficult to determine what you're really getting into. 

Are birth centers licensed, insured?

Hospital and physician affiliated birth centers are licensed and insured, as are the nurse midwives who work in these facilities.

Freestanding birth centers may be insured, but many are not as it is not required by law.  Freestanding birth centers are not licensed through the state of Michigan as facilities.  Some of its employees may be licensed as individual professionals if they hold the appropriate credential (CNM), while other employees are not.  There is no requirement for any midwife at a birth center to have a license.

Are birth centers "accredited"?

Some freestanding birth centers are "accredited" by a national third party who supports regulation.  To find out if your birth center is accredited, please visit this link. Click on the "parents" tab and search by zip code.  If the birth center is accredited, it will say so in parenthesis next to the name of the birth center.  (Note: The Greenhouse Birth Center in Okemos is NOT accredited.  In fact there is not an accredited, freestanding birth center anywhere in MI.)   

What actions would improve freestanding birth centers? 

A freestanding birth center is essentially electing home birth in another house with no regulations, no insurance, and no reporting of outcomes.  In order for birth centers to be considered safe, they must be licensed as facilities & individuals, insured, and required to report all out comes. They should also have a board and policies established to review practices regularly, including insight from outside their own practice.  Even if these practices were in place, proximity alone makes them a greater risk to get the help you need in the event of an emergency.  

What We're Seeking: Is your midwife insured?

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the issue of malpractice insurance, or lack thereof, and its implications for the practice of midwifery in Michigan. 

No one likes to consider bad outcomes when they’re expecting a baby and often they ask the question much too late, does my midwife have insurance?  Some midwives claim that they won’t carry insurance because they can’t afford it or would have to raise their rates which could eliminate potential clients due to higher costs

I would argue that many midwives, particularly nurse midwives, do carry malpractice insurance.  I would also argue that the majority of a midwife’s clients are not low-income families as some may have us believe.  Charging upwards of $4,000.00 per birth is something many families are paying out of pocket to have a midwife attend their birth.  Not to mention that Medicaid now reimburses for out-of-hospital birth, as do many other insurance companies.  (Not because it's safer care, but because it's less expensive for them than a hospital birth.)  The truth is that some midwives don't like to carry insurance because the restrictions that accompany it are too limiting.  Perhaps there is a reason insurance won't cover a breech delivery outside a hospital setting or cover a provider who has had repeated instances of death and injury.  If your midwife is refusing to carry malpractice insurance, it's an enormous red flag about her beliefs and the safety of her practice.  

Let’s think for a moment about the important role insurance plays in the scheme of things.  In order to obtain insurance, a midwife must achieve and maintain a specified level of educational standards.  She must continue her education and be practicing as a licensed care provider.  She must also practice midwifery within a specific scope of practice, agreeing not to take on more than what she can do safely in an out-of-hospital setting.   In order to maintain insurance coverage, she must have a record of safety and good outcomes.  Malpractice insurance serves to protect the midwife from losing everything in the event she makes a mistake.  Insurance also protects families who have experienced negligence. 

What happens when my midwife doesn’t have insurance?  She can practice with or without a license in MI, without being required to have insurance.  (Just because you hire a CNM, doesn't mean she's insured either.)  She may or may not have any defined educational training.  She can attend any kind of birth she wants to attend in spite of what research has determined unsafe.  She can have repeated outcomes of death and injury, but no one will know about it because she doesn’t have to report her outcomes to anyone.  In the event she has acted negligently, she can walk away without reprimand, consequence, or review of any kind.  She puts her own assets at risk in the event of a lawsuit (unless she has placed all of her assets in someone's name other than her own or funneled her profits out of the country…no I’m not making this up, true examples). 

A midwife who refuses to carry malpractice insurance is making a clear statement about the responsibility, or lack thereof, she takes for your care.  The choice not to protect herself by carrying insurance is likely an indicator that she likes to play by her own rules, being accountable to no one.  Choosing a midwife who carries malpractice insurance helps families instantly know that the person they are hiring operates within some sort of safety guidelines & educational standards, and in the event of negligent actions, families will have recourse.  Don't take more risks that you need to: Hire an insured midwife.