The LMPA set the stage not only for the licensing and practicing of LMs but also for the many facets of midwifery training and the educational relationship between practicing professionals and students of the art and discipline of direct-entry midwifery.

The MBC’s Midwifery Licensing Implementation Committee ~ 1994-95

The LMPA identified the MBC as the licensing and regulatory agency for direct-entry (non-nurse) midwives and mandated that such licensing be in place by July 1, 1994. In March of 1994 the MBC convened the Midwifery Licensing Implementation Committee to assist in the process of implementation per the requirements of the statute. This committee met six times between March and September of 1994 and a seventh meeting was held in September of 1995. Each of the seven meetings was approximately six hours in length.

Medical Board member Dr. Thomas Joas, MD was appointed to be chair of the Committee. Other Medical Board officials included lay Board member Stewart Shaw (note: this is a phonetic spelling of an Chinese surname), MBC agency deputy director Doug Lauey, senior counsel Anita Scuri, legislative analyst Linda Whitney and several other former and current MBC staff. The California Medical Association (CMA) was represented by lobbyist Joan Hall and Tim O’Shay. The California Association of Professional Liability Insurers (CAPLI) was represented by retired Judge Cologne. Approximately 12-15 midwives in leadership roles attended these meeting, including myself. The midwives also audio taped the last four meeting (June 1993 to September 1994). These tapes were transcribed and transcripts made publicly available on the Internet at www.collegeofmidwives.org.

During the approximately 40 hours of lively and frequently contentious discussions on a wide range of thorny issues, the topic of midwifery students, the legal implication of student status and/or any Medical Board policies relative to the legal relationship between midwifery students and other licensed professionals (midwives or physicians) was never discussed or identified as a problem to be addressed on a future occasion. There were no Board-approved midwifery training programs in the state at that time and the only route to licensing available to California residents was through the LMPA’s “challenge mechanism”. This permitted ‘qualified’ applicants to challenge the educational requirements of the LMPA and, after satisfying other regulatory criteria, to become licensed midwives under the authority of the MBC.

The Educational ‘Challenge’ Mechanism

The first hundred direct-entry midwives licensed in California since 1949 did so through this challenge process. The law stipulated that the challenge mechanism be administered by a Board- approved midwifery school which would, in essence, require the candidate to test out of a three-year training program. The Seattle Midwifery School (SMS) in Washington State applied for and was approved to administer the challenge program in California.

Applicant midwives were required to establish their eligibility to challenge the educational requirements of the LMPA by documenting the necessary clinical experience as stipulated in regulations promulgated by the MBC. Prerequisite clinical experiences had to be within the previous 10 years and required the applicant to document 235 comprehensive patient-care experiences — 95 initial and follow-up prenatal visits, 40 labors, 20 births as primary attendant and follow-up care for 40 postpartum exams, 40 neonatal exams and 20 well-woman gyn visits. The documentation process required that an MD and a certified nurse midwife both review and sign off on the midwife’s records, which included the names and addresses of all patients.

This paperwork was then carefully reviewed by SMS (including independent verification via letter or phone calls to identified childbearing family). If approved, the candidate was permitted to sit for a series of days-long didactic and clinical exams administered by SMS. These exams conformed to the educational curriculum as stipulated in the LMPA and were equivalent to those passed by SMS graduates. Successful competition of the first three steps qualified the candidate to sit for the state’s midwifery licensing exam. Only after passing the fourth and final hurdle of state boards could the candidate become licensed as a direct-entry midwife.

How or where the prerequisite clinical experiences were acquired by applicant midwives was not stipulated in either the LMPA or pertinent regulations. It was the agency itself that determined the technical configuration of the challenge process via regulations that it promulgated. However, the agency staff informally stated to me (and to agents of Seattle Midwifery School administering the challenge process) that all documents identifying the experiential background that established each applicant’s eligibility must be kept confidential by the midwifery school.

The explanation given was this: If the Board were to be in receipt of any of the documents identifying the applicant’s lay practice of midwifery in California prior to the candidate’s completion of the challenge process and receipt of her license, the agency would be forced to either prosecute the applicant for the unlicensed practice of medicine or the Board would be technically guilty of aiding and abetting the unlicensed practice of medicine. Obviously, this was a ‘catch-22’ premise, as the applicant could not qualify for licensure without the stipulated clinical experience and yet the MBC insisted that such perquisite experience without a licensed was itself a crime. As a result, the challenge process took on an air of “don’t ask, don’t tell” as the MBC attempted to logically administer a program based on this incongruent premise.

The MBC’s Dilemma

The Medical Board found it nearly impossible to harmonize the three fundamental elements of the LMPA, i.e., the professionalization of midwifery through 1) education 2) testing and 3) licensing. Either the LMPA was inconsistent and contradictory OR the MBC interpretation of the statutory scheme created internal conflicts not intended by the framers of the legislation. On one hand, the LMPA described an elaborate and complex system for the comprehensive training, testing, licensing and regulation of the professional discipline of direct-entry midwifery. This was presumed by the MBC to mean that the legal practice of midwifery required that all the various aspects of professionalism be met before any one individual midwife was lawfully “authorized” to practice. However, a plain reading of the text of the LMPA does not actually say this in black letter law.

On the other hand, the challenge mechanism of the LMPA clearly acknowledged in black letter law that traditional (ie, direct-entry, non-nurse) midwifery was, at the time the LMPA was being written, an on-going practice that had existed in a legal limbo ever since the repeal of the midwifery application process in 1949. None of the three statutes dealing specifically with direct- entry midwifery licensing (1917, 1949 or 1993) ever criminalized the practice of midwifery by persons not holding a midwifery license or extended exclusive entitlement to licensed midwives relative to their identified scope of practice – maternity care to healthy women with normal pregnancies. Exclusive entitlement language for midwives was also not included in the LMPA. By convention, it is that exclusivity of licensing that generates the various crimes of practice without such a license.

The LMPA not only acknowledged these simple facts but emphasized professionalizing the formally ‘lay’ practice of direct-entry midwifery via a legislative scheme which permitted “qualified” midwives (who obviously had been practicing midwifery prior to passage of the law) to challenge the three-year educational process. If one ponders that for a moment, it is plain that the Legislature presumed that the hundred or more empirically trained and experienced California midwives could adequately demonstrate the technical skills and a knowledge base equal to a graduate of a formal three year training program. Such an assumption speaks of a basic confidence in this formally disenfranchised and frequently denigrated group. It also appears to recognize that a significant number of healthy childbearing families wanted and had a constitutional right to choose normal birth under the medically non-interventive principles of midwifery.

Implementation of the Licensing Process 1996 to December 2004

In the fall of 1996 a small test group of midwives were walked thru the licensing process by the MBC. This included documents from the Seattle Midwifery School attesting to the successful completion of the challenge process and administering the newly minted state boards in midwifery. By January of 1997 licensing was opened up to all qualified midwives. This was almost 3 years behind July 1, 1994 date set by the LMPA. The midwives felt that the Board was working hard to meet the deadline but frequent changes in the personnel assigned to the midwifery program negatively impacted the Board’s ability to meet these goals.

With the exception of two midwives licensed by reciprocity from Washington State, all California LMs qualified under the challenge process until sometime in 2002 (research date). In 2002 the MBC approved several out-of-state three-year training programs. However, there are still no approved midwifery programs in California. It was not until Board-approved training programs became available that ‘students’ of midwifery became part of the responsibility of practicing LMs. The majority of the Board-approved midwifery programs do not provide internships or resident training, thus all the “hands on” or clinical experience of the student is acquired under a preceptorship arrangement with a practicing LM. Agreeable LMs formally contracted with an individual training program to be designated as a specific student’s ‘preceptor’, and thus to take on the clinical training of that student.

Prior to this, licensed midwives were informally involved as a source of clinical experience for women who were in the process of acquiring the necessary clinical experience for the challenge process. The majority of midwives practicing prior to the passage of the LMPA had many times more clinical experience than necessary and had no reason to acquire additional clinical experience under the tutelage of an already licensed midwife. However, the challenge process continued to be the only pathway into the profession and that eventually generated a small but steady stream of ‘challenge’ applicants who could informally be considered students. The LM- challenge applicant relationship did not have any well-defined ‘rules’ beyond those generated by the common sense of the parties.

In general, these relationships were defined more by the conventions of the LM’s contract with her own clients, which is to say that the student/applicant under the challenge process functioned as an assistant to the LM and did not independently take over the care of the LM’s client. However, within the context of the role of ‘assisting’ the LM, the challenge applicant did perform the full range of clinical skills (vital signs, fetal heart tones, vaginal exams, etc) including being the initial person to go to the mother’s home to determine her status or assess her progress and then report by phone to the senior LM. It also included, at the discretion of the LM and with the permission of the mother, managing the labor and birth and technical procedures such as suturing a minor perineal laceration. It must be noted that this was a necessary prerequisite under the regulations which required the applicant to demonstrate her experience as the primary attendant for a specified number of births.

I cannot emphasis enough that these arrangements had absolutely no antecedent policies or other forms of guidance from any other source – nothing in the LMPA, the regulatory process or any formal or informal policies of the MBA. In particular, the MBC continued to insist that they not want to know what we midwives were doing – “We don’t ask and you better not tell us”.

On many occasions, applicants and candidates for the challenge process and practicing LMs contacted the staff member in charge of the midwifery program with what they considered to be legitimate questions. Many reported that they left 5 or more phone messages without a response and that it often took 2 months before they were called back and even then they had to argue mightily to get the help they were seeking. When the midwifery staff person was particularly unavailable or unhelpful, these women would call me and ask if I could somehow get the midwifery program to be responsive to their issue. Most LMs interpreted the agency’s unwillingness to “help” midwives as an expression of disrespect or even a bias against midwives. All of us felt like that midwifery was the ugly step-sister at the Medical Board.

I tried to mitigate this impression by explaining that some of the expectations of licensed midwives were unrealistic, as the Medical Board didn’t “help” doctors or other licentiates either. Their official role was to simply administer the licensing process – applicants send in the appropriate paperwork and the staff processes it. Until about 18 months ago, this stiff-arm approach consistently communicated the idea that we midwives were “on our own”. Whatever the problem, it seemed that the MBC wanted us to figure it out for ourselves and not bother them.
As a result, California LMs adopted a pragmatic approach in which we sought out advice from one another in an informal network that took the place of official guidance from the Medical Board. I was frequently one of those consulted for an opinion or advice.

Continued –> The Idea that it was “illegal” for LMs to preceptor midwifery students

Contemporary Hx — LMs & mfry students part 3 (of 3)

Compiled from expert testimony provided on March 29th , 2006 by faith Gibson, LM CPM

The first area of interest is the implementation and administration of the licensed midwifery program by the Medical Board of California (MBC) from March 1994 to December 2004.

The second are the standard practices within the California community of the licensed midwives in response to policies established by the MBC; in particular the legal status of candidates for California midwifery licensing under the LMPA’s challenge mechanism and since 2002, midwifery students formally matriculated in midwifery training programs.

I am one of the few individuals in either the midwifery community or employ of the Medical Board who has been involved full-time in these legal and legislative issues prior to and continually since the passage of the LMPA. I have done extensive academic research on the history of the medical practice act and midwifery licensing laws in California and maintain an archival library on the topic. The major sources of documentation quoted here are California medical practice legislation from 1876 to 1993, microfilm copies of state legislature bill sets, official letters of legislative intent, daily newspapers of the era, medical periodicals and the copious records provided by the Directories of Licentiates published yearly by the Board.

I’ve been present at virtually 100% of the public meetings and major events relative to the implementation and administration the midwifery licensing program. I am called upon by Legislative staff or MBC staff members when they require information about customary practices of direct-entry midwifery or the administrative issues relative to licensing.
Institutional memory is a particular issue in regard to the MBC agency staff person assigned to the midwifery licensing program, as there have been 7 different employees in the first eleven years of the program, starting with Tony Arjil in 1994. The position was subsequently filled by Gloria Maceus, Gizzelle Biby, Kim Marquart, Teri Kizer, Susan Lancara and currently is assigned to Mr. Herman Hill*. During the first decade of the midwifery licensing program, the job went unfilled for long stretches. Employment of each of the six initial employees lasted only 6 to 18 months.

* Since the resignation of Mr. Hill in 2005 the job has been temporarily filled for a few months at a time by several MBC staff members and full time by Kathy Burns, Robin Jones, Abigail French and  Cheryl Thompson. Current the contact person is Susan Morrish, for a total of 12 MBC staff assigned to the midwifery licensing program over the 17 years that it has actively administered the issuing of midwifery licenses.

This high turnover and lack of continuity resulted in much confusion for both the MBC staff and for California midwives. In addition, there have been three different executive directors since 1994. As a result of my repeated requests, members of the Division of Licensing have pondered the possibility of a permanent ‘midwifery advisory committee’ for the last 5 years. However this issue was not acted on until the February 2006 quarterly board meeting, at which time it was decided that legislative authority would be necessary. At present no bill has been introduced which would authorize a permanent midwifery advisory committee that could conceivably develop a dependable source for institutional memory and evidence-based policy decisions.

In light of these circumstances, I offer the following background facts as a source of “institutional memory”. The majority of individuals who worked for the midwifery licensing program or participated in the Midwifery Licensing Implementation Committee are either still working for or are available to the MBC and should be able to corroborate the information provided by me. Audio tapes and written transcripts also exist for much of the material relative to the Midwifery Implementation Committee.

Historical Background:

The Licensed Midwifery Practice Act was signed into law in October of 1993. It repealed the 1917 direct-entry midwifery provision of the Medical Practice Act (AB1375-Gebhart Bil-/1917 Amendment to the 1913 Medical Practice Act) which had originally established educational qualifications and standards for the state-certified practice of direct-entry (i.e., non-nurse) midwives. The1917 physician-authors of the original midwifery statue were primarily concerned with setting criminal penalties for midwives who engaged in the unauthorized practice of medicine. The title of the 1917 enactment reads: “to add a new section …relating to the practice of midwifery, providing the method of citing said act and providing penalties for the violation thereof.”

In 73 years of non-medical midwifery practice (from 1917 to passage of the LMPA in 1993) there was a total of 217 California certified midwives. Only 3 disciplinary actions are recorded in the Directories of Licentiates from 1918 to 1950 and all three are for overstepping the identified non- surgical scope of midwifery practice established in the AB 1375 . Certified midwives Marie Caron (FX-83 -1918), Elena Rinetti (FX-97 -1918) and Caterina Reorda, a graduate of the Royal University of Turin (F-58 -1925) all had their licenses revoked or suspended for unprofessional conduct, citing “illegal operation” as the cause of action. It appears from the various documents of the era, including the Directories of Licentiates, that there were no prosecutions for the unauthorized or uncertified practice of midwifery before passage of the original 1917 provision and through out the 20th century until the Bowland case in 1974 — a total of 97 years (1876-1973).

In 1949, at the request of the Board of Medical Examiners, a bill was passed (SB 966) that repealed the application process for midwifery certification (Article 9) and eliminated the midwife classification from the list of certificates issued by the BME. The reason cited was a lack of applicants. Those portions of the midwifery provision defining the extent and the non-medical character of midwifery (Section 2140) and those concerning penalties for unprofessional conduct were left intact (section 2400-08). The 46 midwives who held valid licenses at the time were unaffected. No criminal penalties for lay or uncertified practice were stipulated in this revision. The last state-certified midwife under Article 24 declined to renew her license in 1990.

In the 32 years following the original passage of the 1917 midwifery provision, a qualifying midwifery training program in the state of California was never approved by the Medical Board. This meant that California residents were unable to meet the criteria for licensing. The midwifery provision did not stipulate any courses in professional midwifery itself, but rather mandated that midwifery students complete the same classes in anatomy, physiology, hygiene and sanitation and a 165-hour course in obstetrics taken from the medical school curriculum of physicians and drugless practitioners’ educational standards. Ironically, while mandating the same medicalized education as physicians, the provision itself forbid licensed midwives to utilizing the medical skills taught to them in these classes.

Because there were never any Board approved midwifery training programs, the only source for new applicants were medical students that had completed the obstetrical portion of a medical school curriculum or immigrants – primarily Japanese – who were licensed by reciprocity from one of Japan’s 27 midwifery schools. Due to WWII and the subsequent interment of the Japanese population, the source of new midwifery applicants virtually disappeared after 1942.

From 1949 to 1993, no licensing was available in California for non-nurse midwives. However, the practice of traditional midwifery was not statutorily prohibited in either the original 1917 statute or the 1949 repeal of the direct-entry midwife application, i.e., no provision in the original midwifery licensing law or its 1949 amendment created a public offense defined as ‘practicing midwifery without a license’. Under our form of government what is not expressly outlawed is legal.

A convention of licensing has always been exclusive entitlement in both title and scope of practice in the domain of one’s license. Unfortunately, midwives licensed under the 1917 provision did not enjoy this protection. Unlike the professions of medicine, nursing, dentistry, chiropractic and other allied healthcare disciplines, midwives have never been granted exclusive entitlement for the practice of the midwifery as a regulated profession.

The original midwifery statue was primarily concerned with setting criminal penalties for the use of drugs and “instruments” (i.e., primarily obstetrical forceps) by midwives. The midwifery provision prohibited the use of any “artificial, forcible or mechanical means”, as well as forbidding the use of instruments to penetrate or severe human tissue beyond the cutting of the umbilical cord. These activities were newly defined as an unauthorized practice of medicine and thus illegal if performed by a midwife (except as a medical emergency under section 2063). As for the entitlement issue, these same physician-authors quietly side-stepped the complexities that licensure created by not including exclusive entitlement language for midwives in the 1917 provision.

One practical reason for this oversight is that physicians and midwives share a common patient base – that is, both provide normal maternity care to healthy women. Were midwives to have been granted exclusive entitlement to their own scope of practice, it would have created the ‘unauthorized’ or illegal practice of midwifery. Physicians who also wished to provide normal maternity care to healthy women could be charged with the unlicensed practice of midwifery. This would have required that physicians either become additionally trained and licensed in the discipline of midwifery or that an equivalent midwifery curriculum be incorporated in the medical school education, thus granting exemption to the midwifery licensing law.

During the four decades between 1949 and 1993 the public demand for midwifery care continued on as before, though statistically insignificant as compared to obstetrical care. The 1949 passage of SB966 repealing the certificate classification of ‘midwife’ withdrew the opportunity for future midwives to become state-certified “professionals”, demoting them to the generic classification of “lay” practitioners deprived of professional rights such as employment opportunities, teaching positions and receipt of third-party payments. In the course of my research I could find no records indicating that the Board of Medical Examiners ever viewed the lay practice of midwifery as an illegal activity through out the 19th and 20th century until the Bowland case in1973.

Continued –> Contemporary Hx MBC & Midwifery Licensing ~ part 2 (of 3)

Re-posted from Huffington Post: 03/29/2012

“Midwives have a central focus in our strategic plan. We are hoping Washington State can double out-of-facility births in the next two or three years.”

The speaker was Jeff Thompson, M.D., MPH, chief medical officer of the state of Washington’s Medicaid program. He spoke in a taped interview for Symposium 2012 — Certified Professional Midwives and Midwifery Educators: Contributing to a New Era in Maternity Care. The gathering took place at Warrenton, Va.’s Airlie Center on March 18, 2012.

Thompson, a member of the National Advisory Council for Healthcare Research and Quality, works in the state with the most evidence-based exploration of the value and risks associated with direct-entry, licensed, non-nurse, midwives. His state’s heightened interest began with a state requirement in 1996 that health plans cover midwives. Washington, like 11 other states, presently also covers midwives via Medicaid.

If the certified professional midwives (CPMs) get their way in Congress, CPM services will be reimbursed by Medicaid in all 26 states where CPMs are licensed. Passage would significantly expand access to low-income women across the country. The Access to Certified Professional Midwives Act was introduced in the U.S. House of Representatives in 2011 by Congresswoman Chellie Pingree (D-ME). Passage would energize a slight bump in home births captured in recent data from the Centers for Disease Control.

In addition, the Maximizing Optimal Maternity Services (MOMS) for the 21st Century Act, introduced by Congresswoman Lucille Roybal-Allard, includes CPMs throughout a range of provisions that would effectively foster a renaissance in maternity care in the U.S.

Thompson believes the new states will like the changes these laws would bring: “Midwives have a phenomenal record. C-section rates are lower in those who use midwives.” He said that with low-risk mothers choosing home birth, “We know that the rate is 8 percent, while it’s around 20 percent in an obstetrics facility.” Overall C-section rate ranges from 15 percent from 40 percent in Washington state facilities, according to Thompson. The average rate of C-section is over 30 percent nationwide.

Outcomes on satisfaction with home birth midwives is high, says Thompson: “One issue we can learn from midwives is the customer service in midwifery care.”

Thompson completes the midwives’ “Triple Aim” evidence trifecta with reference to cost. In his state, Medicaid payments to licensed midwives for uncomplicated vaginal birth runs $2,500. Payment for birth center births is $5,000 and doubles again to $10,000 for those performed inside of hospitals. The cost doesn’t touch additional savings from reducing the rate of often over-used medical interventions such as epidurals and inductions of labor.

He closed with reference to the social costs of the current system: “Of the $600 million Medicaid spends annually on hospital costs in his state, 30 percent reflects delivery costs. The unintended consequence of not pursuing something like [expanding the home birth option] is that we don’t have enough resources to spend in other ways.”

The Airlie Center is famous for convening dialogues on peace and justice. A presentation the next morning from obstetrician Tim Fisher, M.D., FACOG, laid out some of the economic power pitted against midwives and rational policy in the battle for control of birth.

A participant asked Fisher whether the new financial incentive in the emerging accountable care organizations (ACOs) might make hospitals more aligned with midwives. If they share in ACO savings, might they proactively refer for lower cost home birth?

Fisher heads up a Dartmouth-Hitchcock clinic in New Hampshire and sits on the Northern New England Perinatal Quality Improvement Network. He ticked off data of another sort. The number one surgery performed in hospitals is C-section. The number one diagnostic-related group (DRG) in hospitals nationally is birth. The number two surgery in hospitals is hysterectomy, often associated with birth. Fisher summed up the importance of current practice to our tertiary care-focused delivery structures: “Birth keeps the lights on in hospitals.”

Hopes of an emerging alignment are not helped by the 2010 position of the American College of Obstetricians and Gynecologists (ACOG), of which Fisher is a fellow. ACOG reaffirmed its position that the college “does not support individuals who advocate for, or who provide home birth.”

Fisher presented the midwives with a strategic recommendation: “Your best move is to go straight to the people who write the checks — go straight to Congress.”

The licensed midwives are in fact three years into a campaign to do just that. The CPMs and the Midwives and Mothers in Action (MAMA) campaign achieved a first victory in 2010. U.S. Senator Maria Cantwell, also from Washington state, included licensed midwives as covered providers in birth centers in Section 2301 of the Affordable Care Act. This put licensed midwives in federal health care law. The focus now is on Pingree’s Access to Certified Professional Midwives Act.

The MAMA Campaign has raised a remarkable $350,000 to support their lobbying effort since 2010, despite counting just 2,000 licensed CPMs nationwide. A former staffer to the U.S. Senate Finance Committee has been retained to support a lobby team led by Mary Lawlor, CPM, LM, MA. The bill has 10 sponsors, all Democrats, including medical doctor Jim McDermott, M.D. (D-WA). Participation from the Republican side has been stifled by antagonism to anything linked to government-run health care.

The midwives assembled at the Airlie Center know that the evidence that pushed the state of Washington to promote home birth may not be sufficient to get the other Washington to turn its back on the likes of ACOG. A major new profession-wide data collection project by the North American Registry of Midwives, the profession’s certification agency, was announced to forceful applause.

Resistance is not surprising. Home birth represents disruptive innovation of the first order for the nation’s hospitals and obstetricians. Moving low-risk birth to our homes or birth centers is a slingshot to the temple of tertiary care-intensive medicine. For a system that leaders of the Institute of Medicine have characterized as half waste and much of that harmful, the home birth model appears a direct hit.

Consider the potentially long-term positive consequences if mothers and families learn that most can have their babies at home, without all that expensive intervention. Might human beings with such an experience of self-care and empowerment in the act of giving birth be more disposed toward achieving self-efficacy in other parts of their care? Might what Washington state is promoting prove an exceptionally powerful force in fundamentally transforming health care?

Lawlor, the MAMA campaign’s point person on the Hill, believes the argument is gaining ground in Congress. She says members and their staffs are beginning to be comfortable talking about the “midwifery model of care.” No wonder. The triple aim of access, quality and cost are all tipped in the favor on this most ancient of innovations.

I am posting the Licensed Midwife Annual Report 2007-2010 Summary here. It is an overview which I compiled of the data from our 2007-2010 Licensed Midwife Annual Report. There is a title/cover page explaining that these are raw data, not research and not a study.

Unfortunately, the file displays the report in landscape because otherwise the data does not fit on the page. You can either tip your head sideways to read it, or (better yet!) print out a hard-copy for easier reading.

UPDATE: The 2011 Licensed Midwife Annual Report has been published. The 2011 comparisons are being added to the overview report, and will be post here as soon as they are formatted. 😉

LMs have been working under a fatally-flawed physician supervision clause since 1993 (19 years and counting!) and CNMs have been burdened by it since 1974 (38 yrs and counting).

A few years ago a third professional group – licensed naturopathic doctors — joined the ranks as providers of physiologically-based maternity care . The law for naturopathic doctors has a carbon copy of the LMPA (which itself is a carbon copy of the 1974 CNM act), which is to say that naturopathic doctors have the exact same physician-obstetrician supervision clause as LMs and CNMs.  While the naturopathic law authorizes the practice midwifery, naturopaths join the ranks of a ‘distinct calling’ — that is, a unique and distinct profession with its own specific professional history, education, clinical training, scope of practice and standard of care  — who finds the ability to function professionally to the full extenct of their scope of practice is legally controlled and restricted by a competing profession.

From a logical standpoint, the CMA and ACOG are right to be concerned that freeing LMs from supervision would be immediately followed by CNMs and naturopaths immediately demanding the same relief. Personally, I think organized medicine is more concerned about competition from CNMs and NDs than LMs providing PHB. Women generally prefer hospital-trained practitioners (CNMs) and hospital birth. People in general prefer practitioners with the word “doctor” in their title, such as Naturopathic Doctors. However, the demand for PHB services has held steady at 1% since the late 1960s. It was the same before the 1974 passage of nurse-midwifery licensing as it was after and stayed the 1993 passage of direct-entry midwifery. Practically-speaking, we do not really represent a threat to the obstetrical profession’s “business-as-usual”.

One of the ways that ACOG and CMA could get themselves out of this conundrum is to agree to let the 2 regulations for LMs go forward (collaboration + access to the 6 necessary drugs), but do so with a great show of public reluctance. That would keep midwives from having to take them to court (starting with the Court of Public Opinion!), which would drag the entire AMA-SOPP mess into the national media and cable news cycle.

But equally important to their goals, our accomplishing what i have described (actual public safety!) via this regulation would not be an automatic pass to either CMN or naturopathic doctors, as these other professions do NOT have the equivalent of SB 1950 — that is, they don’t have a statute that would authorize them to pursue regulatory relief. Both groups would have to go independently to the Legislature to get the equivalent of SB 1950, and still have to fight to get a regulation passed.

Our meeting today primarily concentrated on the proposed regulations that would increase the ability of licensed midwives to function within our license.  With input from Laurie Gregg, OB/GYN, representing ACOG District 9, the proposed regulations were re-crafted and passed by the Midwifery Advisory Council. They will now be presented to the full Medical Board for consideration at the October 26 meeting in San Diego.

It has been our hope that we would have some changes made to the Licensed Midwife Annual Report before we will have to enter our data for 2012. However, due to computer changes that are going on within the Medical Board, there will be no adjustments made by then. Stay tuned for information about any changes that will be made hopefully next year for data reports of our 2013 statistics.

*Agenda item #7: “Consideration of Nizhoni Institute’s ‘Advanced Placement and Transfer Credit Proposal'” as a topic for the Council’s discussion was withdrawn by Medical Board staff Curt Worden. Mr. Worden said new information required additional time by the Staff before it could be considered. For specific details, watch the webcast of today’s Council meeting. {*Nizhoni info added by faith gibson 0n 09-01-12}

Meanwhile, the 2011 Licensed Midwife Annual Report was presented today. Our overall numbers are up in the state, and all data categories show the same basic similarities that have been true in the first four years’ reports. LMs in California are doing good work in taking care of mothers and babies. We hope that the information contained in these       reports can point the way for us to do even better work in supporting California’s families.

PROPOSED REGULATION 1379.23   Physician Supervision Requirement.

(a) The requirement for physician supervision contained in Section 2507 of the Code is deemed to have been met if the licensed midwife establishes a midwife-directed physician-patient consultation for medical indication. The physician must meet the requirements of section 1379.22.

(b) A physician and surgeon shall not be deemed to have established a business relationship or relationship of agency, employment, partnership, or joint venture with a licensed midwife solely by consulting with or accepting a referral from the licensed midwife.

NOTE: Authority cited: Section 2018 and 2507(f), Business and Professions Code. Reference: sSection 2507, Business and Professions Code.

PROPOSED REGULATION 1379.24.  Practice of Midwifery

A licensed midwife shall have the authority, limited to the practice of midwifery as defined in section 2507 of the Code, to obtain and administer immunizing agents, diagnostic tests and devices, and to order laboratory tests. This authority includes, but is not limited to, obtaining and administering intravenous fluids, analgesics, postpartum anti-hemorrhagics, RhoGAM, local anesthesia, oxygen, vitamin K, eye prophylaxis, and family-planning care in accordance with section I.J. of The Standard of Care for licensed midwives.

NOTE: Authority cited: Section 2018, Business and Professions Code. Reference: Section 2507, Business and Professions Code, and Title 16 Cal. Code Regs. 1379.30.

*The next Mfry Council meeting event will be a Task Force meeting September 13th, 1pm to 4 pm. at the Sacramento office of the Medical Board. LMs and students are interested are urged to attend. 

The purpose is to consider the policies and protocols for the legal provision of clinical training to mfry students who are attending labors and births and pre and postpartum-neonal appointments and make recommendations to the Council, who will eventually make recommendations to the full Board. Carrie Sparrevohn and Faith Gibson will be co-chairing the meeting on behalf of the Council. Karen Ehrlich has graciously volunteered to act as an alternative in case either of other Mfry Council members cannot attend.

The next full meeting of the Council is scheduled for December 6th, 2012; 1pm to 4 pm. All MAC meeting are held at the State office of the Medical Board of California. That address is : 2005 Evergreen, Suite 1200, Sacramento, Ca 95815; main telephone  number is 961.263.2389 {*text added by Faith Gibson, 09.01.12}

Originally posted on the CAmidwives Yahoo group after much (confusing) cross-talk about what students are and are NOT allowed to do. Her email included pertinent parts of the LMPA and the text of our regulations.

^@@^

This topic is confusing, and aggravating as well. Yes, we are hoping to convene a task force to hash this all out. Know that everything having to do with Medical Board moves ssss lllllll ooooooo wwwwwww llllllll yyyyyyy. We have no idea when it might happen. Yes, I will post to this list when we know anything about it.

The next Midwifery Advisory Council meeting is August 30 (Thursday) in Sacramento. It is possible that his issue will be on the agenda, but that won’t be known for sure until August 20. Carrie Sparrevohn, current chairwoman, might know that now.

All of what I am explaining here is correct TO THE BEST OF MY KNOWLEDGE. Unfortunately sometimes information changes or opinions change, and then we all have to run like mad to catch up.

If someone who comes to a birth does not do any clinical care at all, she should not have any legal liability or jeopardy. She is acting as a personal attendant to the mother or as an observer or as a potential care provider. She has no clinical responsibility at all. Faith speaks of this person as someone who might help the midwife carry her bags back and forth from the car, or hand things to the midwife, or perhaps help the mother get up and go to the bathroom. She may touch the laboring woman, but not act in any clinical capacity.

The mother has the right to have any number of people present — as long as they don’t do anything that might be considered midwifery tasks.

If the midwife needs to hear fetal hearts while she is gloved up so she can catch the baby, may the observer put a doppler, with audio speaker activated, on a woman’s belly at the request of the midwife? Probably. May she chart at the request of the midwife? Probably. These are among the grey zones that we really don’t know for sure.

If she takes orders from a midwife to do any kind of clinical care, she must be enrolled in a Medical Board approved school, and the midwife she is working with must be contracted as her preceptor. Think belly checks, vag exams, fetal heart checks, perineal support, informed consents, any kind of assessments or clinically-related education or decision making.

The legalese for this is partly in our law, but also appears in our regulations — which carry the force of law. Regulations can only be superseded by new laws or by changes in the regulations. The legislative process is way more difficult to accomplish than the regulatory process, but neither one is straightforward.

And the following are sections from our law. They clearly state that the educational programs must be approved by the board — meaning the Medical Board

2512.5.  A person is qualified for a license to practice midwifery when he or she satisfies one of the following requirements:

(a) (1) Successful completion of a three-year postsecondary midwifery education program accredited by an accrediting organization approved by the board. Upon successful completion of the education requirements of this article, the applicant shall successfully complete a comprehensive licensing examination adopted by the board which is equivalent, but not identical, to the examination given by the American College of Nurse Midwives. The examination for licensure as a midwife may be conducted by the Division of Licensing under a uniform examination system, and the division may contract with organizations to administer the examination in order to carry out this purpose. The Division of Licensing may, in its discretion, designate additional written examinations for midwifery licensure that the division determines are equivalent to the examination given by the American College of Nurse Midwives.

[education details are in the next section of this portion of the law]

(b) Successful completion of an educational program that the board has determined satisfies the criteria of subdivision (a) and current licensure as a midwife by a state with licensing standards that have been found by the board to be equivalent to those adopted by the board pursuant to this article.

If she is acting as primary, she must have the preceptor midwife present on site at all times that she is performing any midwifery tasks — prenatally, during labor and birth, and postpartum.

2514.  Nothing in this chapter shall be construed to prevent a bona fide student who is enrolled or participating in a midwifery education program or who is enrolled in a program of supervised clinical training from engaging in the practice of midwifery in this state, as part of his or her course of study, if both of the following conditions are met:
(a) The student is under the supervision of a licensed midwife, who holds a clear and unrestricted license in this state, who is present on the premises at all times client services are provided, and who is practicing pursuant to Section 2507, or a physician and surgeon.

(b) The client is informed of the student’s status.

If she does not yet have a license in California, she may not do any midwifery tasks and may not do any primary care unless her preceptor is present on site at all times.

If she wants to go through one of the approved schools that has had a challenge mechanism approved, she may not become clinically qualified within California or she runs the risk of being prosecuted in California. The only way she may become qualified via clinical training performed within California is if she is enrolled in a school that is approved by the Medical Board.

The NARM PEP process is not recognized by the Medical Board at all. Anyone who only has a CPM is not a legal midwife in California. In order to be a legal midwife, you must obtain a California license. The only way to get a California license is via a school that has been approved by the Medical Board. The two challenge programs that are possible are through schools that have been approved by the Medical Board, and then went on to apply to the Medical Board to additionally have their challenge approved.

As far as apprenticeship goes, that is such a sore point! When our law was written, there was intent all around (our legislative sponsor and all the midwives who were politically active during the legislative process) that apprenticeship would be supported. But as the laws got written and then the regulations got written, the interpretations by the legal staff of the Medical Board of the language that had been written made that a current impossibility. All three of the midwives who are on the Midwifery Advisory Council were apprentice trained. All three of us speak up frequently at the Council and with the staff (and at the Medical Board when we can) about our support of apprenticeship training. However at this time there is no recourse. The only ways to get licensed are through Medical Board approved schools. Right now, there is no other answer.

Know that the attitude of everyone I have heard discuss this on the Medical Board, including the lawyers and the analysts and the managers, is that apprentice training is substandard. Without an accredited program to rely on, it is their opinion that there can be no trust in the training process, so there can be no trust that the midwife knows what she is doing. The MedBrd wants verification through accreditation processes. That’s why it accepts MEAC — because its accreditation program is accepted by the federal Department of Education. MEAC jumped through tremendous hoops and cranked out mounds of paperwork (and donated countless hours of many women’s time) in order to create accreditation for direct entry midwifery. Without the unbelievably hard work of the MEAC activists, we might not have any educational programs accepted by the Medical Board at all.

I know there is a lot of this that is hard to swallow. Keep in mind that midwives in California decided to go for institutional acceptance and recognition in the 1990s. Since we wanted those perks, we have to accept the system as it is now — as well as keep on working to make it more what we had in mind.

There is obviously lots of work to be done. Please be a part of the process!

The 1993 LMPA modernized the traditional practice of midwifery by incorporating midwifery training that was ‘equivalent but not identical’ to California requirements for nurse-midwives and authorizing the use of a limited number of specified drugs and medical supplies that are for preventive and/or emergent use. This is qualitatively the same as the authorizing legislation of many other non-physician practitioners already referred to in parts one and two of this communication.

* Rhogam for Rh-negative women to prevent fetal death or mental retardation from erythroblastosis fetalis in subsequent pregnancies

 * antibiotic ophthalmic ointment for newborns as required by state law to prevent blindness from ophthalmia neonatorum

 * vitamin K to prevent death or permanent neurological injury resulting from the hemorrhagic diseases of the newborn.

The LMPA also provides for didactic education as well as clinical training in the emergent use of drugs and medical supplies. In addition to 36 hours of CEUs necessary for bi-annual license renewal, LMs must also be re-certified in adult & infant CPR and neonatal resuscitation every 2 year. LMs take the same national neonatal resuscitation course required for hospital NICU personnel. As an interesting aside, obstetricians no longer provide care to neonate at delivery, so while midwives have to be certified in neonatal resuscitation, obstetricians don’t have to be.

Emergent drugs and materials includes:

* oxygen (emergency response to respiratory distress in mother, fetus, or neonate)

* lactated ringer’s IV solutions (severe dehydration or excessive bleeding)

* post-partum use of oxytocins (Pitocin, Methergine, etc) to stop excessive maternal bleeding or stabilize a postpartum hemorrhage while awaiting hospital transport

* injectable local anesthetic and other materials for suturing perineal lacerations

With the exception of oxygen, all the specific drugs noted above were not yet invented in 1917, when the original statutory scheme for traditional midwifery was created. Access to and use of these drugs and medical supplies was specific to modernizing the traditional practice of midwifery in California in 1993. This was based on the established ability of these medical products and pharmaceutical agents to improved patient safety by preventing disease states and providing an effective emergent response to complications that reduce the risk that relatively minor problems will turn into preventable life-threatening emergencies.

While many of these life-saving substances are ‘medicines’ in the sense of pharmaceutical agents, they are not per se the private property of the medical profession. The authority of the medical profession is derived solely from the State Legislature, which reflects the will of the citizens of California to promote public safety through out the health and emergency medical care system. I think most Board members will agree that a huge amount of public and charitable funds (state, federal and private) for higher education and research into many overlapping medical and healthcare fields (including cognitive science and computer technologies) goes to the betterment of the human condition. Ultimately these advances belong to all of humanity, which include making life-saving drugs and medical supplies ‘appropriately’ available to residents of California.

For example, a Quaker wildness camp for teenagers high in the Trinity Alps provides all of its camp counselors with ‘epi’ pens in case one of the kids has an anaphylactic reaction to a bee sting. These counselors do not have ‘physician supervision’ and yet they are not considered to be practicing medicine without a license.

Drugs/techniques in the LMPA that are NOT taught or used by LMs.

While ‘analgesics’ are mentioned in the authorized drugs listed in the LMPA as part of mfry training and practice, no pain medication (either OTC or Rx) are ever administered by LMs in an OOH setting. Period. I carry NO pain-relieving drugs in my little black bag (only ibprophen in my pocket in case i get a headache).

If the non-drug methods of pain relief typically used by midwives don’t work and the mother can’t tolerate an unmedicated labor (or doesn’t progress as expected), then we transfer her to a nearest appropriate hospital. As documented in the LMAR for 2007 through 2011, ‘request for pain medication’ is the single most frequent reason for hospital transfer of laboring clients.

When we arrive at the hospital, a qualified anesthesiologist is contacted and generally delighted to provide epidural analgesia, while both mother and midwife are equally happy that such an effective and safe method of pain control is available. Midwives don’t see this as a ‘failed home birth’ but an appropriate hospital transfer. This means the midwife is doing her professional job, which includes facilitating timely access to necessary medical interventions. As I mentioned at the Feb 3rd Board meeting, midwives and obstetricians are (or are suppose to be) on the same team, working for the same goal – good maternal-infant outcomes, which includes HAPPY moms. I’ve never seen a new mother be happy unless her baby was also healthy.

Para-cervical and pudental blocks are also listed in the LMPA, but use of these techniques are NEVER taught to mfry students, and NEVER used by Cal. licensed midwives. Inclusion of these techniques in our licensing law was a statutory fluke. The author in the LMPA wanted to avoid the public confusion and practitioner inequality and potential discrimination that would come from legislating two different levels or types of midwifery in California. Inevitably one would be considered better and the ‘lesser’ category would be denigrated, thus creating all kinds of mischief.

So Senator Killea copied the wording for the LMPA in toto from the 1974 nurse-midwifery act — same educational curriculum, same scope of practice, even the same misspelling of the word ‘episiotomy’. Since CNMs primarily practice in hospital setting, these anesthetic techniques were appropriately part of the 1974 nurse-midwifery law, but are never appropriate in any OOH setting, irrespective of LM vs CNM licensure.

As you already know, neither obstetrical anesthetic technique is a part of the contemporary standard care for either physicians or midwives. In particular, para-cervical blocks can be extremely dangerous, as injecting a large bolus of Lidocaine (10 cc’s) or similar local anesthetic into the mother’s para-cervical tissue in the few minutes just prior to birth inadvertently exposes the fetus, via transfer from the mother’s blood stream, to an adult dose of this potent drug. This is associated with a profound cardiac and respiratory depression in the newborn (gray baby syndrome).

Para-cervical and pudental blocks are not and will not ever be used by LMs or CNMs. Since passage of these laws in 1974 and 1993, both out-dated anesthetic techniques have been replaced by a much better and safer choice — your favorite and mine — epidural analgesia.

Future Communications

Many other topics vital to the regulatory issues of licensed midwifery were not addressed in this communication.

As I mention when we spoke in person after the Feb. 3rd meeting, an informational 3-ring notebook for new members of the Midwifery Council, agency staff and Board members is available in both hard copy and on-line versions. It provides pertinent background material on the history of traditional (non-medical, non-nurse) midwifery in California and contemporary information on the educational requirements and our scope of practice.

If you will provide me with an office address or PO Box# via return email, I will send you a copy.

warmest regards ^O^

Faith Gibson, LM, CPM, former Chair, MBC’s Midwifery Advisory Council (2007-2010)
Re-appointed in 2010, current Member of the Midwifery Council

[youtube]http://www.youtube.com/watch?v=X7_aUMKMobc&feature=plcp[/youtube]