Wednesday, April 1, 2015

The NC "Home Birth Freedom Act" Supports Midwives at the Expense of Mothers and Babies

The North Carolina Senate is currently considering two bills that deal with non-nurse midwives and home birth. The first - Senate Bill 542 - decriminalizes direct entry midwifery in the state. The second - Senate Bill 543 - sets forth the regulations by which Certified Professional Midwives are to practice.

These bills are being applauded by midwife organizations. The problem? They support midwives, but not mothers and babies.

As Lana Muniz explains in her excellent piece, Maryland and North Carolina Consider Legalizing Dangerous Midwives,

"The bills require:
  • An active license to practice

"They do not require midwives to:
  • Carry malpractice insurance 
  • Report stats to the public
  • Have no VBAC, breech, or multiples at homebirths
  • Have written collaboration agreements" (with a hospital-based CNM or physician)

She points out: 

"If you think these midwifery licensing bills benefit women, you’re wrong. They benefit midwives by allowing them to charge money to attend homebirths without the regulations in place to protect women and babies. North Carolina is not considering any limitations on scope or oversight through collaboration agreements, which means that midwives there would be virtually unregulated."

The statistics on non-nurse midwifery in the United States are clear. This excellent study from 2014 found that home births in the US with non-nurse midwives have a newborn death rate 4 times higher than hospital birth. This meta-analysis from Arizona in 2013 found a newborn death rate 3 times higher at home birth. These 2008 statistics from the CDC Wonder Database found a death rate 3.5 times higher at home birth. This study from Oregon in 2012 found that newborns died 9 times more often at home births attended by non-nurse midwives than at hospital births. And this study, released last year by the Midwives Alliance of North America, found a death rate 5.5 times higher at home birth (for low-risk pregnancies; for breech babies the death rate was 28 times higher). 

And death, although the worst, is not the only negative outcome. This study found that babies born at home suffer 17 times as many brain injuries as those born in the hospital. This study found that 3 times as many babies born at home have seizures. And this study found that 10 times as many babies born at home have a five minute Apgar score of 0.

One of the big reasons why these statistics are so awful is because Certified Professional Midwives and other direct entry midwives - who attend the huge majority of home births - do not have the proper education, regulation, oversight, or accountability to safely care for mothers and babies.

Different Types of Midwives

There are several different types of midwives in the United States and if you're not familiar with all of them their titles can sound similar and confusing. CNM, CPM, CM, DEM, LM...what's the difference? As Danielle Repp explains in her series "American Midwives": 

"There are two midwifery certifying bodies in the USA: American Midwifery Certification Board (AMCB) and North American Registry of Midwives (NARM). The AMCB is considered the Gold Standard for midwifery certification and is the certifying body for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs); NARM is the certifying body for Certified Professional Midwives (CPMs). Licensed Midwives (LMs) also fall under NARM as it is the NARM entrance exam they take. Specific requirements for LMs may vary by state in order to take the exam."

"So in short, midwives in the USA basically fall into one of these three categories:
1. AMCB certified
2. NARM certified
3. Uncertified"

She continues:
"1. Certified Nurse Midwife (CNM)"

"Certified Nurse Midwives (CNMs) are some of the most highly skilled and educated midwives in the world. The Certified Nurse Midwife is one of the only types of midwives in the world that requires a nursing degree. The CNM also holds a master’s degree as the minimum level of educational requirement (some have doctoral degrees). CNMs must complete their education through an ACME-accredited midwifery program (ACME = Accreditation Commission for Midwifery Education). Once completed, they can apply to take the AMCB certification exam."

"Certified Nurse Midwives are licensed and have prescriptive authority in all 50 states (and other territories of the USA). The educational and clinical skills training of the CNM not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, andent of sexually transmitted diseases."

"2. Certified Midwife (CM)"

"The Certified Midwife (CM) credential has existed since 1994. The CM is the direct-entry version of the CNM. While CMs do not need to have a nursing degree, they must take all of the nursing school pre-requisites (such as anatomy, physiology, microbiology, etc) and must receive a bachelor’s degree and master’s degree. The CM’s educational and clinical skills training is similar to the CNMs, as it again not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, and management of sexually transmitted diseases."

"3. Certified Professional Midwife (CPM)" - {This is the kind the bills would legalize in North Carolina}

"The Certified Professional Midwife credential ... was developed as a direct-entry route to become an out-of-hospital midwife. CPMs are not authorized to work in a hospital setting."

"Certified Professional Midwives do not have any degree requirements. The only educational requirement is to have a high school diploma, which was not a requirement until September 1, 2012."

"The Portfolio Evaluation Process (PEP) is a popular route to become a CPM. It is an apprenticeship where the student midwife follows and learns from a preceptor midwife. After attending 40 births (and the prenatal exams leading up to it), the student midwife can qualify to take the NARM exam. Anyone with a desire to become a midwife can seek out a preceptor. Half of CPMs have earned their credential through the PEP route."

"Another route to become a CPM is to graduate from a Midwifery Education Accreditation Council (MEAC) school. There are nine MEAC schools in the USA, some of which award certifications, some diplomas and some degrees."

"CPMs not have prescriptive authority in any states (in certain states, CPMs are able to obtain certain medications, such as Pitocin, Cytotec, antibiotics, etc but CPMs cannot write prescriptions). CPMs also would not qualify to practice midwifery in other developed countries due to the lack of formal education requirements; the CPM requirements also do not meet the International Confederation of Midwives (ICM) standards."

The above was all from Danielle Repp's series American Midwives, part 1, part 2, and part 3; emphasis mine.

I want to repeat - Certified Professional Midwives - the kind of midwives the senate bills are set to legalize in North Carolina - do not have any educational requirements other than a high school degree. And if they became a CPM before 2012, they don't even need that. They don't need to take basic college biology. They don't need to take anatomy, or physiology, or microbiology, or immunology. Heck, as a stinkin' zoologist I have more formal education on the human body than many CPMs.

So if the NC "Home Birth Freedom Act" passes, CPMs, who would not be qualified to practice in any other developed country in the world, will be able to legally practice midwifery in North Carolina. I can't call what they're doing practicing medicine, because they don't consider what they're doing practicing medicine. In Bill 543 they claim "Midwifery is a profession in its own right, and it is not the practice of medicine." That's right - determining the medical condition of a woman and child, ordering labs, giving medicine, and dispensing medical advice, is not, according to these bills, "practicing medicine."

How these two bills could be improved

They could scrap them. Seriously. Certified Professional Midwives do not have adequate education to safely care for women and babies, as has been shown in study after study after study after study.

But if the authors of these bills are determined to push them through despite the increased risk of newborn death, maternal death, brain damage, and seizures, there are several different ways they could improve them.

1. Require malpractice insurance

First of all, the authors should require midwives to have mandatory malpractice insurance. In a report comparing different state midwifery laws, "Do State Midwifery Laws Matter?", the data shows that requiring midwives to carry malpractice insurance cut the rate of newborn deaths in half. Additionally, it does not restrict access to CPM care.

This simple and effective way to protect women and children - requiring midwives to carry malpractice insurance - is not currently a requirement in Senate Bills 542 and 543, despite data showing that it halves newborn death rates without decreasing access to care.

The first section of Bill 543 claims "Access to prenatal care and delivery services is limited by the inadequate number of providers of midwifery services, and the practice of midwifery may help to reduce this shortage." It also claims "In the interest of public health, the State should promote the regulation of the practice of midwifery for the purpose of protecting the health and welfare of women and infants." If this is true - that the bills are being passed in the interest of women and infants - then they will require mandatory malpractice insurance. Women and children are the ones who benefit from the mandatory malpractice insurance requirement - and they benefit a lot. If the bills are truly being passed in their interest, that requirement will be included.

If, however, the bills are being passed in the interest of midwives, they will not - as they currently do not - require midwives to carry malpractice insurance.

If the authors of the bill continue to leave out this simple, effective protective measure, it will be clear that these bills are for the benefit of midwives, not for the benefit of women and children.

2. Require collection and publication of birth outcomes

As it currently stands, midwives do not have to report the outcomes of births under their care to any governing body. If the authors of bills 542 and 543 are determined to pass them despite studies showing increased risks to women and children, they should at least include a requirement that birth outcomes of CPMs must be collected and publicly reported. 

The state of Oregon has this requirement. "In 2011 the Oregon House Health Care Committee amended the direct-entry midwifery—'DEM'—law to require collection of information on planned place of birth and planned birth attendant on fetal-death and live-birth certificates starting in 2012."

"Oregon now has the most complete, accurate data of any US state on outcomes of births planned to occur in the mother’s home or an out-of-hospital birth center."

What did they find? That out-of-hospital birth with a non-nurse midwife had a death rate 9 times higher than hospital birth. (Report here.) This is the type of birth that North Carolina Senate bills 542 and 543 are promoting - out-of-hospital births with non-nurse midwives.

If the authors of these bills still want to pass them despite knowing of the greatly increased risks of non-nurse midwife care to mothers and children, they should at least require collection and publication of birth outcomes. This will help identify problems in the system and provide more information to mothers deciding on care providers.

3. Define "normal" pregnancy and care transfer guidelines

As the bills are currently written, CPMs are allowed to "provide care for the healthy woman who is expected to have a normal pregnancy, labor, birth, and postpartal phase." The problem is that the bill provides no definition of "normal." So the decision of what constitutes a "normal" pregnancy is left up to the midwives themselves, and that is a loophole that will be taken advantage of.

Other countries that have well integrated home and hospital birth systems, like the UK and the Netherlands, have strict "risking out" criteria for who is a good candidate for home birth and is "expected to have a normal pregnancy, labor, birth, and postpartal phase." These criteria are standardized and plainly written out, and if a woman develops any of the risk factors  listed she is transferred from a midwife to a higher level of care.

Common risking out criteria include breech births, multiples, previous cesarean sections, and much more. Consider the differences between the transfer care guidelines of the Netherlands vs. the state of Oregon: Dutch Homebirth Standards vs. Oregon Homebirth Standards. Now think about two things: the Netherlands standards for what constitutes a "normal" pregnancy are much, much higher. And even though Oregon does have some pregnancies that direct-entry midwives are not allowed to care for, Oregon non-nurse midwives still have a newborn death rate 9 times higher than hospitals.

The North Carolina "Home Birth Freedom Act" defines no risking out criteria at all. How high will our death rates be? If the NC legislators want to protect women and babies, they will define what constitutes a "normal" pregnancy and what risk factors will necessitate a transfer of care.

4. Require written collaborative agreements with a hospital-based CNM or physician

As it is currently written, the NC "Home Birth Freedom Act" grants direct-entry midwives the freedom to take on any clients whose pregnancy they themselves define as "normal," have multiple negative birth outcomes without reporting the results to anyone, and experience no financial or professional repercussions. The midwives are essentially free agents. They have no supervisors to ensure that they're working within their scope of practice and they report their results to no one.

In a word, there is no accountability.

If the authors of this bill want to protect women and children, they will make sure that the CPMs they legalize are working within their scope of practice. To do this, they need to require written collaborative agreements with hospital-based CNMs or physicians.

New Jersey's midwifery laws are a good example of this type of supervision. They read:

"a) Prior to beginning practice as a midwife, a licensee shall enter into an affiliation with a physician who is licensed in New Jersey
b) The licensee shall establish written clinical guidelines with the affiliated physician which outlines the licensee's scope of practice.
c) The clinical guidelines shall set forth:
  1. An outline of routine care;
  2. Procedures the licensee will perform or provide;
  3. Procedures to follow if one of the risk factors from N.J.A.C. 13:35-2A.9 and 2A.11 is encountered;
  4. The circumstances under which consultation, collaborative management, referral and transfer of care of women between the licensee and the affiliated physician are to take place, and the manner by which each is to occur
d) A licensee shall provide clinical guidelines and the identity of his or her affiliated physician(s) to the Board upon request.
e) The clinical guidelines shall include provisions for periodic conferences with the affiliated physician for review of patient records and for quality improvements.
f) A licensee who practices without establishing clinical guidelines with an affiliated physician commits professional misconduct as proscribed by N.J.S.A. 45:1-21(e)"

Such standards ensure that all mothers and babies under the care of CPMs are protected by ensuring that CPMs are working within their scope of practice, care is transferred if a pregnancy becomes high-risk, and outcomes are known and documented by a supervisor.

The NC "Homebirth Freedom Act" currently grants too much freedom to poorly-educated midwives, without putting into place safety barriers that will protect mothers and children.

Certified Professional Midwives do not have enough education or oversight to safely care for mothers and babies. As the Senate Bills are currently written, there are no limitations on their scope of practice as long as they claim they believed the mother's pregnancy was going to be "normal." There is no oversight of their practice to ensure they are taking on only low-risk clients, and there are no governing bodies that they have to report their outcomes to. Basic protective measures such as mandatory malpractice insurance and written collaborative agreements are missing.

If the senators in North Carolina still want to pass this bill despite knowing of the increased rates of neonatal death, maternal death, brain damage, and seizures that occur with non-nurse midwife care, if they want to show that they are truly thinking mothers and babies, and not just furthering midwives' interests, they will: 1. Require midwives to carry malpractice insurance 2. Require collection and publication of birth outcomes 3. Define "normal" pregnancy and care transfer guidelines 4. Require written collaborative agreements with hospital-based CNMs or physicians

If these provisions are included in the bills, it will show that they are being passed with mothers and babies in mind. If they are absent from the bills - as they currently are - it will show that the NC "Home Birth Freedom Act" is more concerned with benefiting midwives than providing safe care to mothers and babies.

If you are in North Carolina, please make your voice heard and speak out against Senate Bills 542 and 543! To find out who your senator is, go to this page and click on your county on the "North Carolina Senate" map: Who Represents Me? Your senator's page will have their office's phone and email information. If you aren't sure what to talk about, you can bring up the points that I talked about in this article. Here is a sample email that you can send: Sample Email Against NC Senate Bills 542 and 543.

If you are in Harnett county, like I am, our senator is Ronald J Rabin. He is actually one of the two primary sponsors of the bills, so if you contact his office and make your voice heard through phone or email, we may really make a difference.

Senator Rabin's contact information (found here) is:

Phone: (919) 733-5748
Email: (or - I used both emails.)

Please, if you are in North Carolina, tell your senator to vote no on bills 542 and 543!

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