California College of Midwives

The best way to understand the contemporary politics of allopathic medicine in California is to peek behind the curtain of our state’s modern-day Medical Practice Act to its original 1876 “Healing Arts Act” and California’s first attempt to legally define and regulate the use of the word “doctor”.

So here is a brief historical account of licensing for medical doctors, beginning in California in 1876. It helps identify how state medical licensing laws, in conjunction with the national agenda of organized medicine, impact the professional practice of midwifery and other non-allopathic healthcare options.

California gained statehood in 1850, but the first legislative secession was not held until 1876. A progenitor medical practice act passed that year mandated state licensure for doctors under a legislative heading known as “The Healing Arts”.

The purpose of these new laws was to assure competent practice by those who called themselves doctors. Licensing laws restricted those who could legally use the title“doctor” to medical practitioners who “qualified”. Statues defined this as the ability to demonstrate knowledge of the biological sciences as they pertain to the practice of medicine (i.e. pass a written and oral state board), and the ability to apply medical knowledge and clinical skills by successfully graduating from a medical school in their particular discipline.

The original practice of medicine as a “Healing Art” included homeopathy, naturopathy, osteopathy, allopathic, chiropody (foot doctor) and a category called “eclectic”. This described physicians who used an eclectic blend of ‘natural’ and allopathic of methods. Doctors who did not use any allopathic drugs when treating patients were licensed as “drugless practitioners”.

The original ideas conveyed by the words ‘medicine’ and ‘medical’ did not refer to the use of drugs or surgery or any other specific modality, but to the general activity of a trained person treating the ill and injured by a variety of methods. The word ‘medical’ comes from a Latin root that means: “to heal or cure”. The ancient idea of ‘physician’ originally described someone who provided physical services (i.e. not mental, spiritual or religious) in the field of bodily health. This can still be seen in our use of the word “medic”.

As the art and science of restoring or preserving health, the essential core of medical practice focused on the ‘doctor-patient relationship’ — a mutually-beneficial ‘therapeutic relationship” between the patient and the practitioner. This ‘healing relationship’ was irrespective of the particular method of treatment used by the physician. Based on this historic definition of medicine as a Healing Art, the Medical Board issued licenses in 5 specific categories representing each discipline. The holder of such a certificate was licensed as a ‘physical healer’ and fully authorized as an MD to enter into therapeutic relationships in California.

This all changed drastically in the wake of the AMA-sponsored 1910 Flexner Report (see “AMA, NMA and the Flexner Report of 1910” prepared by Dr. Olakanmi, MD). Publication of this report forced the closure of non-conforming medical schools as defined by the AMA, which included all medical schools that taught any kind of non-allopathic method of treatment. An extremely high percentage of schools that accepted women students, immigrants and non-whites were also closed, citing their inability to live up to the “high standards” set by the AMA’s Council on Medical Education for allopathic medical education.

The mania to purge the medical profession of ‘irregular doctors’ also fueled an on-going national campaign to eliminate the non-allopathic practice of medicine in general. By 1911, the California medical practice act no longer licensed the Healing Arts of homeopathy, naturopathy or ‘eclectic’ physicians. Those already licensed in such disciplines were permitted to practice, but no longer had a role in governing the medical profession.

Until 1910, the California Board of Medical Examiners was composed of 6 non-allopathic and 5 allopathic doctors recommended by the professional organizations of the various disciplines. After the 1911 amendment to the medical practice act, the only discipline allowed sit on the Board’s governing panel were 12 allopathic doctors (same as today). The practice of medicine was no longer functionally defined as a ‘healing art’, as the general title of ‘medical doctor’ and the word ‘physician’ were now restricted to those who treated with drugs, ionizing radiation and surgery. Non-allopathic disciplines were denigrated as quackery and its practitioners labeled charlatans; many were prosecuted for illegally practicing medicine.

The legacy practice of midwifery becomes the unloved and ugly step-sister of the medical profession

Not long after the publication of the Flexner Report the legacy practice of midwifery as an honorable profession and respected public service began a long slow slide into its current role as the unloved and ugly step-sister of the medical profession. As a non-medical (i.e. non-allopathic) discipline, the legal tension between allopathic medicine and midwives remains unchanged. Community-based midwifery as a ‘low medical-intervention’ model continues to be contrasted with obstetrics’ ‘high medical-intervention’ model and defined as substandard. According to MDs, midwifery is both aberrant and dangerous.

It should be noted that that AB 1375, which authorized the first midwifery licensing law in 1917, never referred to it as a licensing act. All other state-licensed health professions – doctors, nurses, dentists, even state-certified nursing assistants – are entitled to the exclusive use of their professional title after their name (MD, RN, DDS, CNA, etc) and exclusive access to a unique scope of practice—all except for the midwifery profession.

The 1917 midwifery provision and subsequent licensing acts for both CNMs and LMs midwives do NOT entitle midwives to an exclusive scope of practice as midwives, that is, providing normal maternity care for essentially healthy childbearing women. While we have a professional title (CNM, LM), we do not have exclusive rights to provide the services within our official scope of practice. MDs however have always enjoyed an unlimited scope of practice that legally encompasses all aspects of the ‘Healing Arts’, including maternity care to healthy women.

As a point of contrast, Article 24 states the purpose of the original midwifery provision as “relating to the practice of midwifery, providing the methods of citing said act, and .. penalties for the violation thereof.” As plainly explained, AB 1375 gave the medical profession legal control over the practice of midwifery, with rights to ‘cite said act’ and impose ‘penalties’ on its practitioners. The biggest issue was boy toys vs. girl toys — keeping the girls from playing with the boy’s toys.

AB 1375 legally prohibited midwives from using private formulary preparations, that is, making up their own medicinal ‘products’ or drugs (a common practice for MDs). It also prohibited the use of surgical instruments except for sterile scissors to cut the umbilical cord, or anything else remotely associated with the practice of allopathic medicine. Strict adherence to non-medical policies even forbid midwives from manually removing a retained placenta when a new mother was hemorrhaging, even if necessary to save her life. Threatening to revoke a midwife’s license would assure compliance; if that didn’t work, midwives would be criminally prosecuted for practicing medicine without a license.

AB 1375 simply declared that: The holder of a license to practice midwifery is not authored to practice medicine or surgery. This 1917 phrase was later inserted by medical lobbyists into the CNM licensing laws in 1974 and the LMPA in 1993.

Nonetheless, I think midwives got the ‘last laugh’, since we don’t want to practice medicine or compete with the obstetrical profession. We like our ‘girl toys’, such as patience with nature, full-time presence of the midwife during active labor and right use of gravity during the pushing phase.

Some of us think the principles of physiological management and associated skills help laboring women to get the baby out even better than many of the ‘boy toys’ that obstetricians are so fond of.

I’m one of those people.

NOTE: This essay has become far too long for its previous title as a “Short” History of Midwifery.

Since it covers more than 165 years of sociology, the politics of organized medicine, and legislative history of both non-nurse and nurse-midwifery, I still think its ‘short’ but many of my readers didn’t agree.

I’m currently editing it into a 4-part series that will have the same content, but be easier to read.

 Prepared by Faith Gibson, LM

I have a three-ring notebook with over 200 pages of historical and political documents supporting the events described below. I’ve provided hard-copy references when available, and URLs links when any of the material was available on-line.  Reading historical source documents provides a fascinating insight that can’t be matched by the brief descriptions in this short history.

When documents are available on-line, I cited each paragraph individually, using sequential letters in parenthesis (a) (b), etc that each letter correspond to the specific link.

However, I suggest reading the entire document first and then returning to read the additional information provided in the links. 

FOREWORD:

Midwifery is the first organized healthcare discipline, with historical roots that trace back 5,000 years to ancient Egypt.

A healthcare discipline is one that protects, promotes and preserves health. Maternity care in particular is concerned with preserving, protecting and promoting the health of already healthy childbearing women. Historically midwives have provided maternity care as a supportive and non-interventive process now described as ‘physiological’ management.

In geographical locations and historical times periods where statistics for childbirth in essentially healthy women are available, the supportive and non-interventive care of experienced midwives has proven safer than the medicalized care of physicians. While this is counter-intutitive statement, the explanation is straightforward and well-documented.

Down through the ages, male doctors prided always prided themselves for providing care that was very different, and according to them, better than that of female midwives. The higher rate of complications associated with physician care was the result of medical interventions used routinely (such as injections of narcotics during labor) and surgical procedures (episiotomy, forceps and manual removal of the placenta). Whenever physiologic support for childbirth is surplanted by invasive procedures, the number and severity of  iatrogenic or nosocomial complications is greatly increased.

Obstetrics and gynecology is an allopathic surgical speciality that treats the pathologies of female reproduction relative to infertility, pregnancy, childbirth and tumors of female reproductive organs. Obstetricians are authorized to prescribe drugs, perform diagnostic procedures, medical treatments and perform surgery.

In the 20th century a bright-line distinction between the non-allopathic practice of midwifery and allopathic practice of medicine developed in the United States, but not in most other developed countries. This is the time and place where midwives in the US became a

Midwifery in the US is a non-allopathic disciplines and its licensed professional are not authorized to prescribe drugs or practice medicine. This is not perceived by midwives to be a problem, since their professional role is to monitor the health of pregnant women and new mothers, assist them to maintain or improve their health status by providing information, and to advise and referral childbearing women to medical services whenever such as is indicated.

 The Social and Political History of Midwifery in California: 1850 to 2014

On September 9th, 1850, when California became the 31st state in the Union, midwifery was a lawful but unregulated activity practiced by empirically-trained midwives.

The legacy practice of midwifery became an independent profession in 1917 after an amendment to the California Medical Practices Act (AB 1375) created a traditional or ‘non-nurse’ category of a state-certified midwife (a) (b).  A licensing program was developed by the California Board of Medical Examiners (now called Medical Board of California) that required licentiates to have graduated from a Board-approved midwifery-training program and pass a state exam. The majority of state-certified midwives were Japanese-Americans who trained in one of the 27 professional midwifery schools in Japan ( c ).

Links (a) 1917 Sacramento Bee newspaper report of the Gebhart bill & legislative intro to AB 1375 (b) title page Medical Board’s Directory of Licentiates – 1918 (c} List of Medical Board-approved midwifery training programs 

After 1917 the only exception to graduating from a midwifery training program was a “grandmother” clause (a) that required practicing midwives to apply for a state license within 180 days. To qualify, they had to satisfactorily document equivalency in knowledge and skill, and provide letters of recommendation by two professionals willing to attest to their good character. The statute recommended that at least one reference be from a doctor familiar with the midwife’s practice and the second from her priest, minister or rabbi. (b)

Links (a) AB 1375’s grandmother clause; (b) List of midwives licensed under grandmother clause 1918-1929

During the next 32 years, 217 midwives (a) were licensed under AB 1375 to provide non-allopathic care as independent professionals (b). Over these three decades of public service only 3 midwives had their license revoked as reported in the Medical Board’s directory of its licentiates.

Links (a) Medical Board Directory of Licentiates, Summary – 1878 to 1950; 1949 memo ~ Gov. Earl Warren Office ~ mfry was independent profession under AB 1375

SB 966 ~Midwifery Suddenly on the Chopping Block

In spite of this impressive record, the midwifery-licensing program was suddenly dismantled in the summer of 1949 (a) by SB 966 at the request of the medical lobby and with the support of the Medical Board. This occurred without the prior knowledge of the midwifery profession.

Links (a) bill set for SB 966 – (a-1) MdBd Director Arnerich (a-2) Director Public Health (a-3) Attorney General 

There was a perverse kind of symmetry in this unilateral action by the medical profession. Both SB 966 in 1949 and the midwifery provision AB 1375 in 1917 occurred without the prior knowledge or participation of practicing midwives. Article 24, which was the midwifery provision within AB 1375, was passed before women had the right to vote. It stated the purpose for creating the category of state-certified midwives was: “providing the methods of citing said act, and … penalties for the violation thereof“.

While midwifery was an independent profession [see link for “memo from Gov Warren’s office” above], Article 24 gave the Medical Board the authority to prosecute midwives if they did anything the agency defined as an unauthorized practice of allopathic medicine.

In 1917, Article 24 of AB 1375 drew a bright line between “boy toys” (the use of drugs, surgery and ionizing radiation) and “girls toys” (non-allopathic management of normal childbirth). This gave the Board the right to revoke the license any midwife caught using ‘boy toys’.

In 1949, SB 966 the medical community used its legislative authority to repeal the midwifery certificate, thus eliminating non-allopathic profession of midwifery and making it’s practice illegal.

(b) published version of SB 966 – repealed application for license & deleted the category of state-certified midwife 

This decision was explained by the Director of the Medical Board, James Arnerich, in his July 1, 1949 letter. He said midwifery was “almost a dead class”, as only two applications for licensure had been received in the previous years [see above link for “bill set for SB 966, ref #1”].

It should however be pointed out that the majority of professional midwives in California were of Japanese descent, and the time period under discussion was shortly after WWII. Just months after the US declared war on Japan, all Japanese-American citizens were ordered into interment camps by FDR’s Executive Order 9066. The Japanese population on the West Coast was relocated to Arkansas, Arizona, Hawaii, Utah, Wyoming, Canada and other locations including rural and desert areas of California.

Links (a) partial list of midwives in out-of-state internment camps 1942-45

A letter in the SB 966 bill set from the director of the Public Health noted that only 456 births (0.2%) in California were attended by midwives in 1946. Perhaps because internment camps were federal government facilities, the category of birth attendant (midwife, doctor) and place of birth (out-of-hospital) were not recorded by the Department of Public Health. [see link above for “bill set for SB 966, ref #2”]. Whatever the reason, almost no midwife-attended births were registered in California during and following WWII.

As for new mfry applications, the Medical Board never approved any midwifery training programs in the state of California after passage of AB 1375 in 1917. The Board did however note that medical school graduates could qualify for midwifery licensure. However the graduates of 58 midwifery programs worldwide (seven other states, and six foreign countries, including three in the USSR) were approved for licensure in California. It’s just that none of these many training programs had campuses in California.

After having been interned during WWII and cut-off from the 27 midwifery training programs in post-war Japan, there was no reasonable access to midwifery training for the vast majority of Californians. The equation is simple — without schools, no new graduates, without new graduates, no new midwifery applications. [see above link for “Medical Board-approved midwifery training programs”]  

Hostility against Japanese-American citizens immediately after WWII may have played a part in the decision to eliminate midwifery. But the more important sociological influence was simply the end of the war and the need to create jobs for returning doctors. Thousands of physicians were released from their military service in 1946 and headed home to open new medical practices.

For the last two hundreds years, the medical profession officially recommend that doctors provide maternity care was the best ways to start a private practice, as women “tenderly delivered” could be counted on to recommend their doctor to family, friends and neighbors. This personal referral network was doubly important for GPs who also provided medical services to men of all ages, children and older women.

Just as”Rosie the Riveter” and the other women who ran the factories during the war suddenly found their jobs being given to returning soldiers, so “Martha the Midwife”and her colleagues were seen as taking jobs from doctors who were presumed to be more entitled and (of course) they had a family to support.

A little social engineering easily eliminated this problem by just leaving the last of the four categories of certificates in the Medical Practice Act off the list legally identifying those authorized to practice in California. Nothing in the legislative’s introductory description, or the actually text of SB 966 pointed out that a legislative technicality had repealed the midwifery licensing law and summarily ended the professional of midwifery in California.

What is so cleaver about this legislative trick is that not a single word of it shows up on paper, and yet its absence is what makes the law change.

Final published version of SB 966 – repealing Article 9 (application for mfry license) & Article 3, Chaper 5, Division 2 (eliminated state-certified midwives from the list of MdBd licenses)

So “Midwifery Certificate” that was fourth on the list simply did not show up on the new list. As published in SB 966, there were only three licensing categories and midwifery was not one of them. While women had the right to vote in 1949, they had little political influence over the content of legislation and were no doubt to learn that midwifery was now “a deal class”.

Using this kind of ‘invisible ink” will show up again in the legislative history of midwifery in California.   

A Historical Aside ~ the new surgical specialty of obstetrics becomes the standard of care for normal childbirth in the US early in the 20th century.

Information about the historical development of obstetrical profession in the US is necessary to understand the issues facing midwifery in the 20th and 21st century. Historically, obstetrics was a medical discipline provided by general practice physicians. When a patient needed a surgical procedure or Cesarean section, they had to call in a gynecological surgeon. There was a high level of animosity between the two professions. To end fights over their respective scope of practice, an influential leader the late 1800s talked the two disciplines into joining together as one profession, which became the new surgical specialty of obstetric and gynecology.

This new American speciality coincided with an extraordinary transitional period of time that was right on the cusp of what we now call ‘modern medicine’. This 75 years period of time was immediately after the discovery of germs as the cause of childbirth-related infections, but before the discovery antibiotic drugs to treat potentially lethal infections in new mothers.

The years between the discovery of the Germ Theory in 1881 and before the wonder drugs we call antibiotics became available in 1945 were both frustrating and pivotal in the shaping of obstetrics as the preferred provider for childbirth care. The perspectives and policies developed during this 75 years period intimately defined the role and customary practices of obstetrics for the entire 20th century, and continues to define its practice in the 21st century.

For the first time ever, microscopic bacteria had been identified as the cause of the frequent, and frequently fatal childbirth infections that doctors were forced to deal with on a daily basis. At the same the obstetrical profession was frustrated by its total inability to treat these potential lethal infections. The only logical response was to do everything humanly possible to prevent women from acquiring an infection during the course of their hospital care.

It is a happenstance of history that efforts by obstetricians to prevent puerperal in hospitalized maternity patients during this pre-antibiotic era permanently shaped the obstetrical profession. Its original perspective on the nature of childbirth and its policies, practices and protocols promoting the ‘preemptive’ use of medical and surgical interventions originated during this time period, and continue to define obstetrics today.

Human history from Adam and Eve to the end of WWII (1945) occurred before development of antibiotic drugs that could prevent women from dying of a childbirth-related infection. During this pre-antibiotic era, obstetrics in American became a new surgical specialty  during very end of the 19th and very earliest decades of the 20th century.

During this era, the American obstetrical profession became convinced that childbirth in human females was a pathological process. Because it routinely injured or even killed otherwise healthy childbearing women, it seemed to them that Mother Nature intended for women to be ‘used up’ in the process of giving birth, the way salmon die after spawning.

Obstetricians characterized pregnancy as a “nine-month disease that required a surgical cure”, which meant a doctor was needed to provide the necessary ‘surgical’ intervention. Because the obstetrical profession saw childbirth as irredeemably dangerous, it concluded that no amount of medical intervention was ever too much.

To prevent these tragic deaths, medical and surgical  interventions were developed during the 19th and 20th centuries to treat potentially fatal complications. The next logical step was to use these allopathic  interventions preemptively or ‘prophilacticly’ during labor and birth in healthy women, in hopes of preventing or at least reducing the incidence of these complications.

In the early 20^th century, one of the most frequent causes of childbirth-related death was “childbed fever” [i.e. or puerperal sepsis, which was a form of ‘blood poisoning].After the baby and placenta were delivered, the place where the placenta was previous attached to the inner wall of the uterus is a large open wound. bacteria introduced into the childbearing woman’s genital track during the labor and birth can easily ascend into large open blood vessels and invade the bloodstream, causing septicemia.  This cruel infection caused newly delivered mothers to die just days after giving birth. Often their babies also died from this infection. Before the invention of antibiotics, there were no effective treatments once a new mother or baby became infected.

The very nature hospitals, which care for the sickest of the sick, also naturally concentrate virulent germs that are associated with outbreaks of lethal infections in post-op patients and newly delivered women. A minority of obstetricians concluded that childbed fevers were a modern disease associated with hospital lying in wards, since the fatal post-operative infection were extraordinarily rare in births that took place outside of the hospital. However, when poor and homeless pregnant women were aggravated in charity hospital maternity wards. Ff the 10 indigent women who gave birth each day, it was not unusual for 1 or 2  of them to develop a fatal fevers and die within the next 3 to 7 days.

at that time, no one, including doctors, understood that contamination by microscopic bacteria and other invisible pathogens caused infectious disease. As a result, they also didn’t understand the role that allopathic medical and surgical treatments played in spreading these fatal infections, especially in hospitalized patients. The frequent use of invasive procedures introduced hospital strains of virulent germs to healthy patients, or spread the germs of infected patients to the staff and other patients. In contemporary times, infection acquired during hospitalization are called a “nosocomial disease”. But these ideas were not yet recognized when obstetrics was first developing a new profession that provided hospital-based care for normal childbirth.

But in the early 20th century, the inability of doctors to treat childbirth-related infections made the prevention of puerperal sepsis such a very high priority. The obstetrical profession decided that the use the techniques introduced by Dr. Joseph Lister to make surgery into a sterile procedure needed to be used during the 2nd (or pushing) stage of labor, when the baby is actually being born. In order to Listerize this phase, obstetrical management of “the delivery”  was defined as a surgical procedure.

Hospital-based childbirth services were aggressively promoted by the medical profession as the new, modern and therefore ‘safer’ way to have a baby for families who could afford it. Obstetrical management began by routinely medicating laboring women with Twilight Sleep drugs administered by L&D nurses. Normal birth conducted as a sterile surgical procedure that could only properly be performed under general anesthesia. It included the routine performance of an episiotomy, forceps, manual removal of the placenta and suturing of the perianal incision.

This represents the most profound change in childbirth practices in the history of the human species.

When the ‘proper’ care for childbirth was seen from this perspective, the non-allopathic discipline of midwifery was judged to be dangerously old-fashioned and totally irrelevant in the world of ‘modern’ medicine. Unfortunately, no one questioned the replacement of physiologically-based childbirth services with obstetrical interventions and invasive procedures or as realized that their routine use on healthy childbearing women was itself risky.

By the 1950s non-allopathic midwifery had indeed become a ‘dead class’ and was seemlessly replaced by obstetrics as the universal standard of care in the United States for all childbearing women.

Midwifery re-emerges as the allopathic discipline of Nurse Midwifery

Programs for training registered nurses in a medicalized model of midwifery were seen as a time-saving device for obstetricians. To free up obstetricians to attend complicated cases and perform more surgeries, Certified Nurse Midwives (CNMs) could provide routine, low-level care in doctors’ offices and hospitals.

In 1974 a nurse-midwifery law was passed in California defining the CNM practice of midwifery as a medicalized discipline under the control of the medical profession in a category referred to by doctors as “physician extenders”. The formal ‘legislative intent’ for licensing RNs with advanced training in midwifery also enabled the newly created profession of nurse-midwifery to provide cost-effective maternity services (including care of the newborn) and well-woman GYN care to MediCal-eligable families, thus reducing the economic burden to the State.

In the role of physician extenders (also called ‘mid-level practitioners’), CNMs were required to practice under the supervision of an obstetrically-trained physician with hospital privileges. This was described as a “commonsense” safety measure to provide an immediate “stepping stone” to physician consultation for non-urgent issues, and a seamless transfer of care whenever a client’s medical needs exceeded the CNM’s scope of practice. While the new category of nurse-midwives were legally required to practice under obstetrical supervision, the law did not require any California obstetrician to provide this legally-mandated service.

For the last four decades, California CNMs have only been able to practice with the cooperation and supervision of an obstetrician. Unfortunately, the obstetrical profession generally sees any independent practice of midwife as an economic threat, and so obstetricians are not as a rule very cooperative.

In addition, supervision of midwives is a legally-entangling arrangement that creates vicarious liability for the doctor. To protect their companies from such lawsuits, malpractice insurance carriers prohibit physicians from supervising any midwife who provides birth services unless its in a hospital L&D unit and is consistent with current standards of obstetrical medicine as an allopathic discipline.

From the standpoint of the obstetrical profession, the primary focus of nurse-midwifery was how its disincentives impacted obstetricians. They had a strong desire to eliminate economic competition from CNMs and avoid the preversly complicated relationship that enmeshed supervising physicians in liabilities issues and expensive malpractice premiums. What was suppose to be a safety net that provided a series of stepping stones to childbearing families in need of medicalized care turned into a stumbling block. A far more accurate description is a brick wall.

The supervision provision expected obstetricians to voluntarily take on unlimited vicarious liability for the midwife’s practice and do so without any economic compensation. Obviously this was never going to work. 

For the lucky few CNMs who could find a supervising physician (not many) their practice was restricted to protocols that met with the approval of medical malpractice carriers. This meant CNMs couldn’t offer any true “alternatives”to customary obstetrical practices. Last but not least, the expense associated with midwife-deliveries in the hospital was the same as vaginal delivery by obstetricians, so nurse-midwifery didn’t provide any cost-savings to the State’s MediCal program.

 Background Maternal ~ Addendum #1 & 2  ~ {WORKS-N-PROGRESS}

Statistical Facts about the Safety of Childbirth, part 1  ~ what everybody needs to know in order to make sense of the “midwife problem” and why would anyone seek out “alternatives” childbirth services when obstetrics appears to be the obviously safer and superior choice?

The Safe Childbirth Practice ~ the Difference btw Obstetrics & Physiologically-based Care, part 2

 Attempts to Get Out of the Straight Jacket of Physician-controlled Midwifery

In 1977 Governor Brown’s first administration described the impasse over mandatory physician supervision as “structural barriers to practice” which prevented nurse-midwives from providing services to low-income women and families seeking alternative care. The Department of Consumer Affairs, an agency under the executive branch of California government, actively supported passage of a new midwifery-licensing law as an independent discipline that was not controlled by the medical profession  [AB 1896].

Link to original and re-typed version of 11-page document supporting AB 1896 by Deputy Director Michael Krisman, Sept 8, 1977

From  1977 to 1992 consumers, midwives, and at times the DCA, all energetically lobbied for a total of six midwifery licensing bills. However there was endless, scathing and even vicious opposition  by members of the obstetrical profession to each and every one. As a result, all efforts by midwives and mothers failed. Then in 1990 Senator Lucy Killea agreed to try again. Given her extraordinary background, she was the perfect person for the job.

During WWII Senator Killea had been an ‘operative’ (i.e. spy) for US Army Intelligence while stationed in Europe. In 1947 she and her husband Jack Killea were two of first three people hired by President Truman to run the brand new Central Intelligence Agency.  As a member of the California Legislature, Senator Killea consistently supported women’s reproductive rights, which made her a target for political retribution. As a result, she became the first Roman Catholic in the US to be excommunicated by her parish for her legislative voting record.

Link NEWS UNDER THE RADAR – March 9, 2011; Lucy Killea’s CIA Network; Matt Potter alleges illegal evidence gathered by CIA operative Jack Killea

Bitter-Sweet Success ~ the Licensed Midwifery Practice Act of 1993

After 3 years of tireless effort by Senator Killea, midwives and grass-roots activists, the Licensed Midwifery Practice Act (SB 350) was passed in 1993. Its educational requirements and scope of practice were specifically developed to be ‘equivalent but not identical to nurse-midwifery’. But again vehement opposition by the medical lobby resulted in the same deal with the devil – the LMPA was burdened with the impossible definition of midwifery in the 1974 CNM law – a medicalized discipline under the control of the medical profession. The legal issue of physician supervision was another matter. It was a real and immediate problem that created a 20-year stand-off between midwives and organized medicine.

The first skirmish began with seven day-long meetings of the “Midwifery Implementation Committee” held from March of 1994 to September of 1995 at the MBC Sacramento office. The meetings were chaired by Dr. Thomas Joas, an anesthesiologist and seated member of the governing board. In addition to midwives, the other “interested parties” were the California Medical Association (CMA) and the California Association of Professional Liability Insurers (CAPPLI).

I wish I could say we devoted those 50 hours over 18 months identifying the characteristics of midwifery as a non-allopathic discipline and how that made it distinct from the allopathic specialty of obstetrics. Another good choice would have been developing a first-class standard of care for the community-based practice of midwifery. Or we could have worked out reliable methods of communication between the new profession of licensed midwifery and the Medical Board. The favorite on my wish list would have been a method to provide the Medical Board with statistical information about the clinical practice of midwifery by tracking the overall performance and safety of midwifery care provided by its new licentiates.

But alas we spend 50 grueling and exhausting hours arguing over tiny little every aspect of physician supervision!

Twenty years latter this is amusing to remember, but it was no fun at the time. In addition to the boredom of obsessive conversations about supervision, nothing we did during those 50 hours that supported, promoted, or advanced the professionalism of California licensed midwifery. It was all about supervision, all the time, with every real and imagined aspect put under the microscope and discussed ad nauseum.

Most of the Committee’s time was focused on how the allopathic obstetrical profession could define ‘supervisory relationship’ to its economic advantage by controlling the non-nurse, non-allopathic discipline of midwifery. Of equal concern was protecting obstetricians from vicarious liability. This was in part accomplished by insisting that any obstetrician who had a professional ‘association’ with a home birth midwife would automatically loose their med-mal coverage.

At this point, Judge Cologne (former attorney with the anti-trust division of the Justice Department and current lobbyist for CAPPLI) reiterated the favorite solution or organized medicine: licensed midwives should just limit themselves to ‘performing’ hospital deliveries just like nurse-midwives, and all would be well!

When midwives pointed out that supervision didn’t work for CNMs who were providing hospital-based services, and certainly wouldn’t work for us since we were only providing care for planned home births, the conversation would inevitably turn to “clean up legislation”. Committee chair Dr. Joas spent considerable time emphasizing the need for clean-up legislation and that it was up to us as midwives to take these problems back to the Legislature to broker a legislative ‘remedy’.

I tape-recorded 3 of the 7 meetings and transcribed several of the tapes. Had LMs gone to court to get the ‘supervision provision’ judicially set aside, these written transcripts all by themselves would have made our case.

Here are links to the transcripts:

Links: MBC-Midwifery Implementation Committee, Meeting #3, June 6, 1994 Tape 1 {Dr. Shelly Sella}, Tape 2  {Senator Killea}, Tape 3 {Juudge Cologne}; Meeting #6— September 94 {Nancy Chavez, Anitia Scuri}

There was however one aspect of this 50-hour marathon that produced a concrete result, albeit not a helpful one. The American College of Obstetricians and Gynecologists convinced the MBC to pass regulations requiring each LM to have a written supervisory agreement with an obstetrician [see August 11, 1994 letter from ACOG to the MBC and OB-Gyn News September 15, 1993]. Based on the terms of these written agreements, each supervising physician would have ultimate authority, responsibility and liability for the midwife’s practice.

ACOG president Dr. Vivian Dickerson provided their wish list to the Board in her 08-11-1994 letter. The Board believed that obstetricians were obviously the experts in childbirth and logically should set the regulatory rules for midwifery practice. As a result ACOG’s letter became the template used by the Board for the proposed regulation.

When comparing ACOG’s letter and Section 2507 of the LMPA, one finds NO instances of the words “written practice guidelines” in the LMPA, while the August 1994 letter and the proposed regulation both contained four. When ACOG’s letter was laid side-by-side and compared line-by-line to the proposed regulation, 55 out of the 120 words in the letter also appear in the proposed text of 1379.21, using exactly the same placement, vocabulary, syntax and word order — in other words, a cut-and-paste job.

Luckily the ending of this story is anti-climactic. The regulatory hearing for 1379.21 was held November 1994 and submitted to the OAL in October 1995 (OAL File 95-1012-09S). Fortunately for mothers and midwives, the regulation was disapproved by the OAL on ground of “clarity” and “necessity” in December 1995, again in May 1996 and the last time in 1997. At that point, the MBC declined to pursue the matter any further.

Ninja midwives give ACOG a taste of it’s own medicine

Despite this temporary setback, organized medicine continued to vigorously pursue the enforcement of physician supervision. However, licensed midwives just as vigorously insisted that the supervision provision had already proven itself to be a failed system relative to the practice of midwifery as a non-allopathic profession [see above link to DCA 1977 letter].

Given this history, the medical lobby’s imposition of a system demonstrably proven to be unworkable was a ‘disguised restriction’ on the professional services authorized under the LMPA. In addition to violating anti-competive state laws, this was also illegal under the North American Trade Agreement. 

NAFTA’s objective in relation to licensing is to prevent licensing requirements from being “unnecessary barriers to trade”, stating that state licensing requirements must:

“not constitute a disguised restriction of the provision of services ….. Requirements should be based on competence”.

In September 1992, California DCA memo to all its executive officers and bureau chiefs conveyed a request by Governor’s Trade Representative each state agency prepare a plan to implement NAFTA. As a measure of the “anti-competive impact” on licensed professionals, the memo suggested the following questions: 

(a) Are any of your licensing or certification statutes, regulations or procedures not based on objective and transparent criteria such as competence and the ability to provide the service?
(b) Are any of your licensing or certification statutes, regulations or procedures more burdensome than necessary to ensure the quality of the service?
(c) Are any of you licensing or certification statutes, regulations or procedures in themselves a restriction on the supply of the service?

These views were reiterated in a letter dated 01-11-94 from the Federation of State Medical Boards by Dorothy Harwood, who noted that:

“State medical board licensing standards are not pre-empted”.

Judged by NAFTA’s standards of fairness, physician supervision was a dismal failure.

Help from a highly unlikely source

In 1998 licensed midwife Alison Osborn was prosecuted by the MBC for not having a physician supervisor. A 1999 decision by OAL in the Osborn case confirmed that mandatory obstetrical supervision of midwives was a dysfunctional system and therefore unenforceable. Judge Jaime Roman ruled that provisions of the LMPA cannot lawfully be used to make the practice of midwifery functionally illegal.

According to this legal theory, the Legislature’s intention in passing the LMPA was a binding directive to make non-medical midwifery care again available to childbearing women who needed or wanted a professional alternative to obstetrical services. The legacy tradition of midwifery had already been an independent profession in California from 1917 to 1949 under Article 24 but its licensing provision was dismantled in 1949 at the request of the medical lobby. Passage of the LMPA demonstrated the Legislature’s intent 45 years latter to restore access to midwifery as a modern-day, non-allopathic profession authorized to provide maternity services to essentially healthy women.

Judge Roman’s decision stated that any licensed midwife who had documented a workable plan for consulting, referring or transferring care to an obstetrician or the obstetrical unit of a hospital had fulfilled the “ambit” of this provision. While medical lobbying groups continued to be outraged over this ruling, they also never had a ‘cease and desist’ order served on the MBC for failing to prosecute hundred of midwives for openly practicing without supervision over a 20-year span of time.

In 2000 a bill that amended the LMPA for the first time was carried by Senator Liz Figueroa (SB 1479) at the request of licensed midwives. It reduced some of the legal burdens of the unworkable supervision provision by implementing aspects of the legal theory in Judge Roman’s 1999 decision.

The amendment required each planned home birth (PHB) client and midwife to identify arrangements for medical consultation, referral or transfer of care during the prenatal, intrapartum and postpartum-neonatal period that were specific to that particular client. The form included the name of a physician who could be contacted and/or concurrent care (ex. Kaiser) and identified a geograhically-accessible hospital that the mother or baby could be transferred to if necessary. These arrangements were to be memorialized in writing, signed by mother and midwife and become a permanent part of the client’s midwifery record.

In addition, SB 1479 included a “Legislative Intent” section that acknowledged, as a matter of California state law, that childbirth was a normal aspect of biology and not a medical disease. It also identified physiological management — the supportive, non-interventive practices associated with the community-based midwifery — as a non-allopathic discipline that is clearly distinct from obstetrical practice.

The midwifery model of care included:

• informed choice
• continuity of individualized care
• sensitivity to the emotional and spiritual aspects of childbearing
• monitoring the mother throughout the childbearing cycle including
  her physical, psychological, and social well-being
• providing individualized education, counseling, and prenatal care
• continuous hands-on assistance during labor and delivery
• postpartum support
• minimizing technological interventions
• identifying and referring women who require obstetrical attention

Furthermore, the “Intent” language in SB 1479 legislatively upheld the right of essentially healthy childbearing women to self-determination in choosing the manner and circumstance of normal childbirth. This was a ‘corrective’ response by the Legislature that addressed two issues in a 1976 California Supreme Court ruling.

In a criminal case brought against three lay midwives in Santa Cruz county in 1973, the Bowland Court ruled against the defendants by stating that pregnancy and childbirth as defined by the Medical Practice Act was a medical condition, thus making midwifery an unauthorized (thus illegal) practice of medicine. Bowland further noted that a pregnant woman’s right to choose a non-physician birth attendant or alternative birth setting had never been legally established, since the California Legislature “had never gone so far” as to acknowledge the right of women to control the “manner and circumstances” under which they gave birth.

SB 1479 corrected both those problems. As mentioned earlier, the “Intent” language identified childbirth as a ‘normal bodily function and not a medical condition’, and also established a woman’s right to choose alternative birth settings. It cited evidence-based studies on the relative safety of alternative birth settings published in California and other countries that supported planned home birth as a responsible choice for essentially healthy population of childbearing women with normal pregnancies.

In 2002 another amendment to the LMPA – SB 1950 – was sponsored by licensed midwives and authored by Senator Liz Figueroa. It contained a regulatory process for creating a professional standard of care for the community-based practice of midwifery. This ultimately required the Medical  Board to abide by a midwifery standard when judging the merits of a complaint against a midwife licentiate, instead of having the agency ask an obstetrical consultant’s opinion.

Achieving consensus between the MBC, ACOG and licensed midwives for ‘state of the art’ evidenced based practice was long and very difficult, but the Standard of Care for California Licensed Midwives (SCCLM) was finally completed, approved by the MBC September 15, 2005 and adopted by the OAL March 9th, 2006.

In 2004 midwives approached Senator Figueroa again and asked if she would be willing to carry yet another piece of legislation, this time to create a Midwifery Advisory Council and Licensed Midwives Annual Report (LMAR). It took two years to work out the details, but SB 1638 was signed into law in 2006.

While the MBC is the regulatory agency for the licensed practice of midwifery, there was no regular, 2-way communication between midwives and physician-run governing Board. SB 1638 created a Midwifery Advisory Council under the auspices of the MBC to provide a cooperative interface between the state agency, its governing Board and its midwife licentiates.

The law specified that at least 50% of the Council’s members should be licensed midwives, while the remaining portion should be consumers with “an interest in midwifery”.  Apart from identifying the categories of public and professional members and specifying the ratio, SB 1638 otherwise left the Advisory Council’s configuration to the discretion of the MBC.

The Medical Board interpreted the word “consumer” as used in SB 1638 to indicate any citizen in California that was not a professionally licensed midwife. Obviously obstetricians and Medical Board members are ‘not midwives’ and presumably have some general ‘interest’ in midwifery, so the Medical Board created a six-person council by appointing a member of its own governing Board, two ACOG-certified obstetricians and three licensed midwives.

Midwives objected to this overly-broad interpretation of ‘consumer’, which is generally defined in this context as a non-professional who uses the professional service being regulated. The idea of obstetricians being appointed as “consumers” generated many contentious conversations and some hard-feelings on both sides. Finally in 2012 the Board agreed to replace one of its obstetrician-members with a consumer who had used the childbirth services of a licensed midwife.

Currently the MBC schedules three half-day Midwifery Advisory Council meetings a year.

One of the Midwifery Council’s first tasks was to implement the LMAR, which required the Council to create statistical reporting form many pages in length along with an instructional manual. Aside from an occasional complaint, the MBC had absolutely no information about the overall performance and safety of midwifery care as provided by its licentiates.

The LMAR created a new web-based statistical system run by the Office of Statewide Health Planning and Development (OSHPD) to report annual statistics. Each midwife is required to report the total number of clients served that year, the number who gave birth at home or in a birth center, those transferred to a hospital, reasons and outcomes for all clients regardless of the place of birth. This includes reporting significant morbidity and maternal or perinatal deaths, and the total number of normal spontaneous births and Cesarean sections.

Links to website with document posted about the development of the LMAR

Statistical averages for the 10,668 clients served by LMs between 2010 and 2013 identified a spontaneous vaginal birth rate of 92%, hospital transfer rate of 19%, Cesarean section rate of 8% (nat’l average 32.8%), and a very low prematurity rate of 1% (nat’l average 12%). The neonatal mortality rate for LMs excluding lethal birth defects was 1.3 per 1,000 live births.

National birth certificate data linked to neonatal mortality don’t provide the mortality rate by category of practitioner (MD, CNM, LM, EMTs, etc), or place-of-birth (hospital vs OOH). However, it does report neonatal mortality for term pregnancies (37+ weeks) and babies weighing over 5 ½ pounds. In 2012 (last year data available) that number, which includes birth defects, was a NMR of 2.2 per 1,000 live births.

Relief for mothers, midwives and midwife-friendly obstetricians ~ the long overdue repeal of supervision

Over the 20-year span of the LMPA, three unsuccessful attempts were made to replace mandatory supervision with functional relationship of collaboration between midwives and physicians (AB 1418, SB 1479 & SB 1950). But it was not until 2014 was the supervision provision finally repealed by AB 1308.

As a result of the new legislation, licensed midwifery is once again, technically speaking, an independent profession in California. But unlike the LMPA itself and its first 3 amendments sponsored by midwives, AB 1308 was sponsored by the American College of Obstetricians and Gynecologists (ACOG). While AB 1308 repealed the supervision provision (for which we are all grateful), it also introduced new and far reaching problems.

The Dysfunctional Practice of Midwifery under AB 1308

AB 1308 restricted the midwives’ scope of practice by dramatically expanding the category of healthy women that midwives are no longer authorized to provide childbirth services, or cannot do so without the prior approval of the obstetrical profession.

Since midwifery is a non-allopathic discipline, midwives have always transferred patients with symptoms of a complication requiring medical care to an MD or hospital obstetrical services. Midwives, physicians and the licensing statute (LMPA) all agree that this is as it should be.

There is also nearly unanimous agreement between midwives and physicians on what constitutes a serious “complication” requiring medical attention. As a result there was no need for regulations to define the single word “complication” as used in the LMPA. For over 20 years, the clinical judgement of licensed midwives has proved more than sufficient.

But AB 1308 shifted the non-urgent category of women with a history of a prior complication or current non-urgent risk-factor into the same high-risk category as patients having a complication. The mere possibility of a future complication is being treated the same as a present-tense complication, in that AB 1308  requires the same immediate referral or transfer of care as a ‘complication’. It also applies the same criminal penalties for any perceived failure to refer or transfer. Politically-correct midwives politely describe this as ‘mission creep‘, others not so charitable simply call it a ‘land grap’.

The expanded involvement of the obstetrical profession as mandated by AB 1308 bars any pregnant woman with identified risk factors or medical conditions from making essential decisions about her own health care, even if she has legal or scientific grounds, or declines mandatory obstetrical evaluation for other reasons 

Midwives are not permitted to provide primary care (either prenatal or childbirth services) to such women unless the pregnant woman first agrees to be examined by an obstetrician and the doctor is willing to provide a formal medical opinion that the issue involved is not “likely to affect pregnancy or birth”.

If pregnant women objects to or refuses to being medicalized California LMs as a class are permanently enjoined from providing midwifery care.

AB 1308 also forbids to licensed midwives from caring for childbearing women who have post-dates pregnancies, even thought this means dropping them from care without the mandated requirement that they be given two weeks notice to find a replacement provider. This includes breastfeeding mothers with lactational amenorrhea whose due dates are uncertain. It applies even if the mother-to-be is evaluated by an obstetrician and has sequential ultrasounds that confirmed normal levels of amniotic fluid and non-stressing testing (NST) that indicate normal fetal well-being.

Previously, all these categories were a specific part of the normal informed consent process outlined in Section V of the SCCLM:

Risk factors identified during the initial interview, or arising during the course of care: “Responsibility of the Licensed Midwife” and “Client’s Rights to Self-Determination”

Section V required midwives to advise clients with a history of previous medical conditions or non-urgent risk factors detected during their pregnancy to consult with a physician. However the Standard of Care also acknowledged that childbearing women are mentally-competent adults. After being fully informed of all pertinent facts, they have the legal right to decline this advise as is true for any other competent adult.

When the SCCLM was being developed, ACOG’s Committee Opinions on “Informed Refusal (#166) and “Patient Autonomy: The Maternal-Fetal Relationship” (#214) was the model used to develop the legal language for Section V.   

Opinion #166 (Informed Refusal) notes:

Almost universally, informed consent laws have been liberalized … from the relatively paternalistic “professional or reasonable physician” standard to the “materiality of patient viewpoint” standard. … In the “patient viewpoint” standard, a physician must disclose … the risks and benefits that a reasonable person in the patient’s position would want to know in order to a make an “informed” decision.

ACOG Opinion #214 states that:

• … medical knowledge has limitations and medical judgment is fallible. Existing methods for detection … are not always reliable indicators of poor outcome, and there is often insufficient evidence for risk-determination or risk-benefit evaluation
• The role of the obstetrician should be one of an informed educator and counselor, weighing risks and benefits …. and realizing that tests, judgment and decisions are all fallible.
• Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.
• In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes regardless of the consequences.

ACOG Committee Opinion #214 also identifies serious negative consequences when a patient’s autonomy is violated:

• A woman is wronged and may be harmed, whether physically, psychologically or spiritually.
• The patient’s subsequent loss of trust in the healthcare system may reduce the health care provider’s ability to help her and may deter others from seeking care.
• There may be other social costs associated with this violation of individual liberty.

Nothing I could say in support of the logic, rationality and practical necessity of respecting the autonomy of childbearing women could exceed, or even closely match ACOG’s very own published policies. But apparently ACOG has an unpublished policy that restricts their noble principles to its own obstetrical patients, while not offering this same respect for autonomy to women being cared for by licensed midwives.

Return of the Dreaded Invisible Ink ~ legislative technicalities, circa 2013

AB 1308 employed a little-known legislative technicality to repeal our standard of care (SCCLM) without our knowledge, permission, or even an explanation. Midwives were shocked. The obstetrician negotiating for ACOG at one point said she was really impressed with its quality, so there was never any reason to suspect that our hard-fought-for standard of care was on the chopping block.

The idea of repealing or even changing our Standards was never mentioned during legislative negotiations between ACOG, AB 1308’s author and midwives. Nothing in the bill’s many sequential drafts from February thru September, the legislature’s published synopsis of AB 1308’s important features, or the Medical Board’s final report on the practical effect of the newly passed bill made any statement about AB 1308 having eliminated the SCCLM.

However,  the same ‘invisible ink’ used in SB 966 to end the professional practice of midwifery in  1949 was used again in 2013 to make the SCCLM disappear. The critically informative language — in this case, the words “standard of care” and “repeal” — never appeared on paper during the legislative process and were not in the final version of AB 1308 signed into law by Governor Brown on October 9th, 2013. As a long-time supporter of midwifery, I think Governor Brown would be also be shocked learn that the bill he just signed was in fact a major step backward, as AB 1308 silently revoked the regulation that authorized the SCCLM.

California midwives didn’t even know that the SCCLM had been eliminated from the LMPA until three months later, when this was announced at the December 2013 Midwifery Council meeting. During that meeting, Curt Worden, MBC Chief of Licensing, offered to create a greatly redacted version of our Standards as a unofficial “practice guideline” for midwives. But he emphasized that as informal ‘guidelines’, they would have no legal force and could not be used to defended the practice of a licensed midwife in a disciplinary action. This is in stark contrast to the SCCLM, which required the Board to use a midwifery (i.e. not obstetrical) standard when judging the merits of a complaint.

The MBC’s unofficial version of these guidelines was published May 14th 2014.

Link to the original SCCLM renamed “Practice Guidelines” with strike-thru revisions in red

Loosing our midwifery Standard of Care is the single most detrimental aspect of AB 1308. Its repeal eliminated a pregnant woman’s right to self-determination, the midwife’s responsibility to advocate for and defend the decision-making autonomy of her clients, and the requirement that the MBC use midwifery standards when adjudicating charges against a midwife.

The decision to eliminate the SCCLM also dishonors the huge amount of work by the many people who so diligently to brought it to fruition, starting with passage of SB 1950 in 2002 by Senator Liz Figueroa and her highly committed office staff.

After SB 1950 was signed into law, the MBC staff and consultant Dr Pat Chase labored for many months researching practice standards used in other jurisdictions. In particular, she was attempting locate the most informative and comprehensive definition of “normal” as applied to pregnancy and childbirth.

In a MBC’s document called “Background Material” (October 8, 2004), Dr. Chase wrote: “All states define midwifery as the care for normal, low-risk pregnant women. The clearest definition [of normal] is from the California College of Midwives’ Standard of Care”.

The California licensed midwife provides maternity care to essentially healthy women who are experiencing a normal pregnancy.

An essentially healthy woman is without serious pre-existing medical or mental conditions affecting major body organs, biological systems or competent mental function. An essentially normal pregnancy is without serious medical conditions affecting either mother or fetus.”

As director of  the California College of Midwives, I was honored to have its definition of ‘normal’ used in the final version of the SCCLM. Other source materials were drawn from the “international definition of a midwife” (ICM), state and national midwifery organizations, and standards-of-care published in seven other states, as well as the College of Midwives of British Columbia in Canada.

Once the Medical Board moved into the formulation phase of the SCCLM, licensed midwives, ACOG reps and Dr. Richard Fantozzi (Chair of the MBC’s Midwifery Committee) spent three long years (2003 to 2005) discussing every concept and every word of the proposed standards. In spite of being busy with his responsibilities as president of the MBC’s governing Board, Dr. Fantozzi was generous with his time, open-minded, and intellectually curious. He treated midwives with utmost respect and the issues of midwifery practice with fairness. Best of all, he was fiercely protective whenever other physicians ridiculed midwives or attempted to use their power to disadvantage the midwifery program.

Dr. Ruth Haskins, an ACOG fellow who served on the organization’s internal midwifery committee, and ACOG attorney Shannon Smith-Crowley both contributed tremendously by being a conduit for ACOG’s concerns and objections, and helping all of us work out compromises that were mutually acceptable to midwives and the Medical Board.

Members of the MBC staff also ‘midwifed’ our project, including helpful legal advice from the Board’s senior counsel, Anita Scuri, and administrative support by Ron Joseph, the agency’s executive director until 2004. Legislative analyst Linda Whitney and Dave Thornton, the new executive director, patiently provide additional support, encouragement and helpful feedback. Cheryl Thomson and Pat Thomas worked together to develope the formatting, research spelling for midwifery vocabulary and type the final document so it could be posted on the MBC website. The result of these thousands of hours of effort by more than a dozen people employed in two branches of California government was a first-class Standard of Care that mirrored other standards of high quality used worldwide by professional midwives.

How do we know that our standard was uniquely effective or that California midwives abide by its useful guidance? Ca LMs have been practicing under the SCCLM for 8 years, beginning a year before the LMAR started tracking the safety and effectiveness of midwifery care under the LMPA. As measured by the aggragate statistics for maternal-infant outcomes for 2007 to 2013, the relative safety of non-allopathic midwifery equals, and in some categories (Cesarean rates, prematurity, etc) actually exceeds those of mainstream medicine. The care that California licensed midwives provide in non-medical settings stands on a solid scientific foundation of practitioner competence.

Another measure of the quality of midwifery practice under the SCCLM is the extremely low number of disciplinary actions against LMs. Using the most recent data (fiscal years 2011-2012 & 20112-2013) the Medical Board only pursued administrative or criminal cases against two midwives during the last 24-months. Based on the total number of midwives licensed during this period, this is a prosecution rate of only 0.003.

Obviously the Standard of Care for California Licensed Midwives, which included a midwifery code-of-ethics and fourteen pages of practice guidelines, was a success. Nonetheless, the same Standard of Care was summarily replaced by AB 1308 by a single sentence that requires midwives to:

“immediately refer or transfer… if at any point a client’s condition deviates from normal”

According to the language of AB 1308, a midwife’s license may be suspended or revoked for, among other things, failing to consult with a physician and surgeon, refer a client to a physician and surgeon, or transfer a client to a hospital if the woman has a post-date pregnancy and any condition identified in regulations (currently pending) deemed “likely to affect pregnancy or childbirth”.

Violating any provision of the LMPA is deemed to be a crime.

As of this writing (December 2014), the truly independent practice of midwifery does not yet exist. The ability of licensed midwives to provide individualized care based on “best practices” continues to be distorted and diminished by the overarching influence of organized medicine and its well-funded special interest lobbies.

There are only two options here – door #1 or door #2.

What’s behind Door #1?

Since turn-about is fair play, the first is for organized medicine to invite “organized” midwifery as a non-allopathic discipline to sponsor legislation amending the allopathic practice of medicine.

Personally I’d recommend a new law requiring allopathic medical schools to include courses on the non-allopathic principles and technical skills of physiological management, and as well as development of policies, protocols and education of hospital staff to help reduce our 33% CS rate.

I’d want to passed a “full disclosure” law requiring obstetricians to provide scientifically valid and unbiased information about the medical side-effects and complications that accompany the use of obstetrical intervention and invasive procedures. These include induction of labor, use of Pitocin to speed up labor, routine use of continuous of EFM, episiotomy, Cesarean surgery (13-fold increase in emergency hysterectomy, 6% increase in secondary infertility) and the unique dangers to mothers from abnormal placental implantation associated with repeat Cesareans (7% maternal mortality rate for women with placenta percreta).

The new ‘informed disclosure’ law should also require that obstetricians informed pregnant patients about the modern history maternal mortality rate in the US.  After a hundred years of steady improvement, the MMR became stagnant in 1982 at 8 maternal deaths per 100,000 live births and remained at that level until 1996. Then the MMR began to steadily increase until it reached 17 deaths per 100,000 a couple of years ago. While it the MMR for the last year published (2012) has decreased to approximately 12 deaths per 100,000, the US rate 39th worldwide, making it safer for mothers to give birth in Bosnia that California.

The rising MMR in the US over the 18 years tracks with the increasing CS rate in the US. A large proportion of the increased maternal deaths are directly or indirectly associated with intra-operative, post-operative, delayed and downstream complications of Cesarean surgery. These categories include hemorrhage, pulmonary embolisms, infection and deep-vien thrombosis (blood clots), anesthetic accidents, bowel obstruction, and other iatrogenic complications. Even elective and repeat C-sections where the pregnant woman was healthy and there were no prior medical complications result in several maternal deaths each year.

The Better Option ~Door #2

The other and I think more sensible option is that ACOG apply its own advice about respecting the autonomous decisions of women by expanding these principles to the practice of midwifery. ACOG Committee Opinion #214 states that: “Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.”

This also applies to midwifery. As female midwives, we ourselves are childbearing women and/or daughters, sisters, mothers and grandmothers to childbearing women. For midwives there is no “bright line” distinction between us as women providing a professional service, and us as women who are pregnant or giving birth. Put in the words of ACOG’s committee opinions, we are personally “wronged and may be harmed …. physically, psychologically or spiritually” when our autonomy as childbearing women or as midwives is ignored, disrespected, or trampled on.

ACOG already acknowledges: “There may be other social costs associated with this violation of individual liberty“. There is no “maybe”about it — violations of liberty are harmful, individually and to society.

The cost is a “subsequent loss of trust in the healthcare system” that reduces our ability as healthcare providers to help women who have been harmed in the past by violations of their autonomy, which in turn “deter(s) others from seeking care“.

The most harmful aspect of this gender-related violation of trust is that it often prevents women, as mothers and as midwives, from seeking or respecting the opinions of obstetricians. In this case, a significant number of women who can’t get midwifery care due to restrictions imposed by AB 1308 will have unattended births. Unattended childbirth in women who didn’t receive regular prenatal care results in a 20 to 40-fold increase in neonatal mortality, so obviously denying access to midwifery care is not a ‘safety’ measure.

Any “violation of individual liberty” has a negative rebound effect on society, which is the polar opposite of what is needed.

I’d like to end by telling a story about Eleanor Roosevelt during the time her husband was in the White House. I think it perfectly characterizes the virtuous goals of maternity care. A reporter once asked Mrs. Roosevelt who she put first, her husband as president of the United States, or her children. She replied:

“Together with my husband, we put the children first.”

Midwives and obstetricians need to develop trust, mutual respect and the ability to cooperate, so that together we can put childbearing women first.

Part Two – a companion document on the Healing Arts ~ a peek at the history of the modern-day Medical Practice Act:

http://californiawatch.org/dailyreport/death-rate-childbirth-rises-california-10038

A possible win-win for mothers and midwives vs. business-as-usual

Since the 1980s, most L&D units have ‘permitted’ unmedicated women to get out of bed, and fathers and family members are now ‘allowed’ to present for the birth, but this only returns us to the central theme for many contemporary women – the absence of an engaged birth attendant except for the drive-by photo op at the very end.

I purposefully characterized the brief presence of a birth attendant at the end of 2nd stage labor as a ‘drive-by photo op’ to point out the most basic fact of about normal childbirth: babies are not “delivered” by the doctors, but by their mothers.  It is the childbearing woman who gives birth, and the birth attendant (ob-gyn or midwife) who ‘receives’ the infant.

At most normal births, we birth attendants (both physicians and midwives) simply stand very very close to birthing women, and then take all the credit for this miraculous feat of biological engineering and the mother’s grim determination and tenacity of spirit! However, any woman who has just pushed out an 8# baby is not fooled by this little rouse.

From the perspective of the healthy childbearing woman, the major historical and practical difference between obstetric and midwifery boils down to this: Midwives provide a time-tested traditional model of physiological management and are present throughout the intrapartum – active labor, birth of the baby, postpartum and neonatal period.

If the ob-gyn profession were to give needs of such women the same quality of serious attention they already give to the complex management of medical complications, healthy activist women would be ecstatically happy and midwifery would be the last thing on their mind. This shift in the perspective of obstetrics would instantly eliminate the historic economic competition between obstetrics and midwifery. It would also make ACOG members very happy.

All ACOG has to do to negate the ‘competitive threat’ of midwives is simply to steal our thunder. Ob-gyns could provide the very same kind of care as midwives and be personally present during the entire intrapartum period. This would include what older obstetrical textbooks called “patient with nature”, that is attending the active labor of each patient, helping the laboring woman to breathe through each painful contraction, suggesting that she move around, maybe get in a shower or deep tub, and letting her know that you think she has what it “takes” to do the job. As the labor progresses, ob-gyn birth attendants would continue to be physically present to assist the first-time mother try out various positions to assist her to push more effectively. These docs  would of course ‘catch’ the baby, and remain present and actively engaged during the immediate PP and neonatal period.

However, there is another kind of “catch” to one-on-one care — that it require that ob-gyn physicians not perform surgery or otherwise provide any other forms of income-generating professional services during the 4 to 24 hours of intrapartum services for each patient. This would limit an obstetrician’s caseload to the number of labors and births they could reasonably commit to be present for each month. This also presupposes professional acknowledgment that physiologically-based care for the 85% of healthy childbearing women was a proper function of obstetrics and compatible with their scope of practice as obstetricians and gynecologists.

If childbearing women in American are already getting what they want and expect, then direct-entry midwifery as an independent profession that is unable to provide a drop of single pain medication or order an epidural, would have very little to offer that women couldn’t just as easily get from their ob-gyns at a local hospital. Midwives and homebirth would magically vanish without a trace like a bad dream.

New solutions or different problems?

For most obstetricians, the revenue limitations of this plan would be a big problem. There are two obvious solutions.

Option #1: 

The obstetrical profession could partner with professional midwives by integrating the very best scientific and technological contributions of modern obstetrics with the very best evidence-based principles of physiologic care to produce a new, 21st century science-based standard of care for a healthy childbearing population.

The goal is nothing less than an integrated, cooperative and ‘minimalist’ model based on “best practices”.

This would transform our national maternity care policies by reconfiguring the system at its most basic and practical level. Its objective would be to seek out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome for mothers and babies with the fewest number of medical/surgical procedures and least expense to the health care system.

In this new 21^st century system, all L&D units would include a staff of professional midwives. As hospital employees, midwives would routinely provide primary care to healthy women and be present full-time for all normal labors and births. As the identified professional birth attendant, midwives would only call on the patient’s obstetrician if a medical problem arose or the mother-to-be requested care from her obstetrician.

As for the hot-bottom issue of ‘planned home births’ that has so vexed the obstetrical profession, it could easily be solved by the development and proliferation of community-based birth centers primarily staffed by midwives (and a few physicians) who provided physiologically-based care to healthy women with normal pregnancies. Since these facilities would be far more cost-efficient than acute care L&D units, hospitals could eliminate the unwelcomed ‘place-of-birth’ competition between in- and out-of-hospital by investing in ‘off-site maternity homes’. This would be an all-around good business move for everyone and midwives would for sure love them!

Option #2: 

The obstetrical profession could continue to insist that as members of the surgical specialty of obstetrics and gynecology, the activity characterized by them as “labor-sitting”, is simply NOT a part of their scope of practice, nor is it a skill set they have or want to develop.

In the time-is-money department, obstetrician-gynecologists might insist that attending normal labors is a colossal waste of their valuable time when it’s compared to performing surgical procedures. They are often reimbursed as much as $1,500 for ten minutes of work as a surgeon; with the help of a good staff, they can perform and bill for as many as six such procedures in a single hour.

Starting with the standard MediCal global obstetrical fee of $2,500, the physiological management of the intrapartum as a routine practice would require ob-gyn surgeons to voluntarily exchange a surgical reimbursement rate of up to $9,000 an hour for an average hourly rate of $208 as a physiologic birth attendant who provided fulltime intrapartum support. This reflects an average time of eight hours per labor-birth-pp-nn, twelve 1/4 hour prenatals and 1 postpartum office visit, for a total 12 hours.

Back to the beginning ~ the obvious and inescapable conclusion

Is it any wonder that ob-gyns prefer performing Cesarean sections? Or that many healthy childbearing women have unwillingly been forced into political activism? Being in constant conflict with the obstetrical profession is a distasteful situation to many of us, given that most women, myself included, very much like their own ob-gyn.

Over the last two decades childbearing families, now referred to as “consumers”, have partnered with childbirth educators and midwives. All three activist groups insist that what we charitably call our “maternity” care system is not actually, as the name implies ‘mother-centric’ or even mother-friendly.

Our national obstetrical system spends very little time or attention on normal childbirth, seems particularly adverse to discussions about ‘demedicalizing’ labor management, is completely disinterested in actually reducing the CS rate (often referred to “as vaginal by-pass surgery!) or the quality of experience for healthy childbearing women and relationship with their newborn babies.

According to surveys published in 2002, 2006, and 2010 {citation #1} of healthy childbearing women who had given birth within the previous year in American hospitals:

• 93% of obstetrically-managed labors involved an average of seven significant medical interventions — immobilization in bed, IVs, continuous EFM, Pitocin augmentation of labor, bladder catheterization, etc
• 70% of births included a surgical procedure — episiotomy, vacuum, forceps and/or cesarean
• 33% of American babies are now delivered by Cesarean surgery

• maternal mortality in the US stopped falling in 1982; since 1996 MMR has risen to historically high levels for a developed country (the US  ranks 39th worldwide) with the majority of these deaths associated with Cesarean surgery; according to citation #2 below: “over the past 10-15 years, maternal mortality has doubled in the United States and is now comparable to some developing countries”

• premature delivery rates in the US has risen from 8% in the 1980s to 12%.

• premature and sick newborns diagnosed with breathing problems accounts for the single most expensive category of hospital reimbursement for Medicaid

When the CS rate was considerably less than it is today (27% vs. 33%) a study published in the Journal of the American Medical Association (JAMA) admitted that previous decades of escalating Cesarean section rates were NOT associated with any improvement in maternal or infant outcomes.

The study’s conclusion was that nothing from within our institutionalized system of obstetrical care, characterized as it is by “high rates of routine intrapartum interventions”, was able to reduce the very high annual rates of cesarean surgery and other medical interventions. According to their analysis neither highly medicalized labors, nor the liberal use of Cesarean were able to demonstrate a significant and consistent reduction in complication rates or improvement childbirth outcomes.

JAMA “Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial”
2002 Sep 18;288(11):1373-81 Hodnett ED1, et al:

“North American cesarean delivery rates have risen dramatically since the 1960s, without concomitant improvements in perinatal or maternal health.

In hospitals characterized by high rates of routine intrapartum interventions, continuous labor support by nurses does not affect the likelihood of cesarean delivery or other medical or psychosocial outcomes of labor and birth.”

[note: the CS rate was under 5% in 1960, rose to 25% by 1975 during the ‘medical malpractice crisis’, dipped to about 20% for a decade or so, then marched relentlessly higher each year to our current high-water mark of 32.8%]

A report on the cesarean deliver rate by the Medical Leadership Council (representing 2,000 US hospitals), concluded in its 1996 that:

“… the US cesarean rate was … medicine’s equivalent of the federal budget deficit; long recognized as an abstract national problem, yet beyond any individual’s power, purview or interest to correct.”

The conclusions by JAMA and the Medical Leadership Council shouldn’t surprise us, since we obviously have an obstetrically-centric model of maternity care that is failing to meet the biological and psychological needs of its healthy population.

Apparently that is what G*D made midwives for. I say: Viva la difference!

Bottom line, ob-gyn doctors were never trained for, nor have they ever wanted the job of ‘being there’ during the average healthy woman’s often longer, or slower but still vitally important process of giving birth under her own power and at her own speed.

So lets try something different from the last hundred years, which was characterized by futile attempts to deny the obvious.

Let me suggest a big dose of realism instead.

Let’s give up the illusion that major surgery is the best form of care for healthy women and that a surgical specialty is the most appropriate and cost-efficient provider to a healthy population who would be receiving physiologically-base care.

At the same time, let it be OK that obstetrics and gynecology is a surgical specialty. Let’s applaud surgeons for doing surgery when necessary, since we all know that Cesarean sections can and do save lives. On behalf of my family, friends and clients, I am profoundly appreciate of and grateful for such surgical skills.

Then lets move forward and appreciate midwives for patiently providing the safest and most effective form of care for healthy childbearing women — physiological management. A system realistically built on the combined strengths and knowledge of both disciplines (medicine and midwifery) would really be a ‘win-win’ for mothers, midwives and, in my opinion for obstetrical profession, our national maternity care system, and taxpayers.

Let me end with brief historical account:

During the time the presidency of Franklin Roosevelt (1932 to 1944), a reporter asked his wife Eleanor who she put first – her husband or her children.

Her reply was: “together with my husband, we put our children first”.

After a century of unmitigated acrimony between medicine and midwifery, I suggest that today is the perfect time for physicians and midwives to put new mothers and their unborn and newborn babies first.

And by the way, viva la difference!

{1} Listening to Mothers Surveys; Childbirth Connection, 2002, 2006 and 2010

{2} over the past 10-15 years, maternal mortality has doubled in the United States and is now comparable to some developing countries.[3] 

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 May 2. pii: S0140-6736(14)60696-6. doi: 10.1016/S0140-6736(14)60696-6. 

http://www.medscape.com/viewarticle/829465?nlid=63030_1521&src=wnl_edit_medp_wir&uac=145218EV&spon=17

Part 3 ~ Turning a backlash into forward action ~ women’s groups plan to acknowledge and protect the human dignity of childbearing women

As judged by worldwide standards, the historically poor performance of interventive obstetrics in the US represented an uncritical acceptance of an unscientific premise — a ‘one-size-fits-all’ obstetrical model that repeated and continually fails to distinguish between healthy women with normal pregnancies and those with serious complications.

The uncritical acceptance of this particularly unscientific premise didn’t just apply to the ob-gyn profession. It represented the ‘common wisdom’ of all segments of society — the general public, the medical profession, public health officials and the policy-setting functions of state, local and national governments. The underlying problem was a widespread lack of understanding by the public about normal childbirth, and the general behavior of people to trust whatever they were told by doctors.

With this as background it is not surprising that the obstetrical profession didn’t see criticism as indicating either an unscientific practice by the medical profession or a human rights issue. Unfortunately, it was both.

The obstetrical profession’s reaction to its critics was to continue denying the lived experience of childbearing women and ignore the danger resulting in the unwise use of obstetrical interventions. Their unwillingness to make safe and supportive care available — a situation so graphically described in 1958 in the Ladies Home Journal’s  article “Cruelty in Modern Maternity Wards“ — was disturbing enough on its own merits. But the brazen and stiff-armed reaction by doctors doubly incensed many women.

The result was an organized activism by maternity nurses, housewives and grandmothers who’d never before taken a public stand on anything more controversial than PTA elections. These agitators for childbirth reform didn’t think of themselves as “human rights activists” but nonetheless recognized the obligation of civil society to provide appropriate maternity care as a fundamental aspect of human decency.

Where to start, what to do next?

The first attempt at reforming the US maternity care system was insider pressure by L&D nurses. But given the power disparity between female nurses as hospital employees, and the much higher status of a mostly male medical staff, activism by nurses failed to produce any substantial change.

With few resources and very little money, next best idea by birth activists was to organize childbirth education classes for prospective parents. Their goal was the same as the whistle-blower nurses — to replace a dysfunctional system that routinely medicalized healthy women with a responsive one that protected and promoted science-based childbirth practices as they apply to a healthy population.

The original plan was for maternity nurses to offer classes on the biology of normal childbearing. The curriculum was simple and straightforward: Spontaneous labor and birth is a subtle, naturally orchestrated and easily disturbed form of reproductive biology that needs to be carefully watched and supported by professional birth attendants; however, the physiological processes of normal labor and birth are best left undisturbed whenever possible. The role of professional birth attendants (including L&D nurses) is to know and respect these time-tested principles.

Birth educators also realized that perspective parents needed to know about the negative effects of medically unnecessary interventions on the physiological and psychological of childbirth. Routine us of interventions during labor such as being immobilized in bed, frequently repeated vaginal exams and administration of narcotic drugs often disrupts the mother’s biological ability to labor effectively. This is often taken as an abnormality, which triggers a progressive cascade of additional medical and surgical interventions that sometime results in serious complications for mothers and babies.  {😉 for Rosanna}

Childbirth educators hoped that pressure from educated consumers to liberalize hospital protocols would be more effective in the long term than bad press and agitation by hospital nurses. Requests by ‘prepared’ parents-to-be ran the spectrum from simple issues such refusing unwanted drugs and being ‘permitted’ to walk around during labor, to really big ticket items like changing the policies of obstetrical units so the supportive care healthy women believed they deserved became part of a hospital’s routine maternity services.

Birth educator also knew the traditional principles of physiological management, which had been eliminated from medical education in the early 20th century, would need to be included again in the medical school curriculum. Then the new version of mother-baby friendly ideas and associated skills for obstetricians could become normal practice when providing maternity care to healthy women.

Obstetrical pushback: What part of “no-way” didn’t you ladies get? 

Of course the obstetrical profession rejected all this hook, line and sinker, holding itself above such mundane notions as “consumer demand”.  However hospital PR departments were directly in the bull-eye of these consumer demands and this began to move the needle ever so slightly.  The heads of obstetrical departments eventually (abet grudgingly) acceded to requests by parents for de-medicaliing childbirth practices by offering window-dressings that included colored bedspreads and curtains in the labor rooms. In some very ‘liberal’ institutions OB policy even permitted the patient’s husband (occasionally even her mother) to be present during labor, but didn’t allowing either one to accompany the laboring woman into the delivery room.

But as time progressed, many consumer-centric policy brought about by birth educators were directly sabotaged or eroded over time. Yes “they” (L&D nurses) would let you get out of bed and walk around, but that was increasingly impossible for laboring mothers due to the pre-emptive use of IVs and continuous EFM.

As hospitals competed furiously with each other to have the most ‘advent guarde’ maternity department in town, some of the bigger obstetrical units began offering 24-7 access to epidural anesthesia. This became such a ‘hot item’ that it spurred a whole new sub-speciality — that of obstetrical anesthesiology. Suddenly any obstetrical unit could hire it very own anesthesiology staff and successfully compete high-volume regional hospitals. But from the perspective of the obstetrical system, nothing was better for the obstetrical process of total control over childbirth than women immobilized in their beds after being giving an epidural, with all the afford-mentions interventions of IV, EFM, Foley catheter, etc, hanging off their bodies.

Thus was born 21st century obstetrics, which is an even more aggressive use of modern technology married to the same classic 20th century policies and protocols. Its more than a hundred years since Dr. J. Whitridge Williams’ invented the hybrid profession  of obstetrics and gynecology as a new surgical specialty but its basic assumption  — that childbirth is so dangerous no amount of intervention is ever too much — remains the same.

Business-as-usual for American obstetrics includes the routine speeding up of spontaneous labors with Pitocin, routine induction of labors at 40 wks plus 4 days, and liberal recommendations for Cesarean delivery anytime the doctor believes a vaginal birth might not easy (i.e. fear of big-babies). The latest addition is the ‘maternal choice’ Cesarean for women who are to afraid to labor normally, have been frightened into believing the normal childbirth will permanently destroy their vaginas, too busy to take the time to labor normally, and those who suffered childhood physical or sexual abuse that makes the idea of normal birth intolerable to them.

When you mix these practical realities with the ever escalating pressure of the medical malpractice insurers, the result is our 33% Cesarean section rate, escalating maternal mortality rate AND  hospital charges of $50,000 for an essentially normal (abet long) vaginal birth and 24 hrs of just-to-be-safe nursery ‘observation’ of their newborn, with mother and baby both discharged within 48 yrs.

When parents points out the obvious “break-the-bank” aspect of this system, they are accused of being hedonists willing to risk the life of their infants just to have a ‘good’ birth experience.

Ghosts of Christmas Past ~ maternal discontent and community-based midwifery

After more than a century of continuous tension between what healthy childbearing women need and want, and the obstetrical profession’s continuous refusal to acknowledge its validity (and greater safety of physiological management) mothers, midwives and birth activists are exactly where we have been for the last 100 years — yelling into the wind. Virtually everyone else in society thinks we are nuts and that obstetricians are gods.

This brings us back to the direct connection between the re-invention of midwifery and the professional stonewalling of obstetricians – the folks who invented: “we won’t cooperate and you can’t make us ”. In the castle of a hospital labor and deliver unit, obstetricians are still undisputed king.

ACOG’s most recent volley was to use its ability to control the legislative process via Assembly Bill 1308 to take over the California’s Licensed Midwives Practice Act (LMPA) .

The “you-can’t-make-us-cooperate” folks unilaterally repeal the Standard of Care for California Licensed Midwives (SCCLM), which was in place for the last 8 years, without the knowledge of licensed midwives or the permission of California consumers. This summarily eliminated a regulation that previously acknowledged and protected the constitutional right of self-determination by healthy childbearing families. This important provision had wisely allowed parent to decide to whether (or not) to be medicalized for a potential risk based on a direct understand of what was in their own best interest.

In the place of parental self-determination, ACOG mandated involuntary obstetrical referral for women with certain risk factors. If a woman refuses obstetrical evaluation, or declines obstetrical advise to be prophilacticly-medicalized (a response the new bill acknowledged as lawful) AB 1308 turns the LMPA  into a ‘denial of services’ document that prohibits Ca LMs from attending their births.

From the legal standpoint of midwives, the unilateral manipulation of our licensing act constitutes restraint of trade/unfair business practice described as a “disguised restriction on the provision of services”.  From the perspective of childbearing families, our midwifery licensing law was turned into another mechanism for the obstetrical profession to violate the human rights and dignity of healthy adult women to choose the manner and circumstances of a normal childbirth.

The result of these provisions in AB 1308 is yet another re-invention of lay midwifery. The affect of this new law has already increased the number of unattended births for women who were otherwise unable to receive physiologically-managed care for a normal labor and birth. While unable to get the ‘system’ to take their needs seriously, these unfortunate women were still legally blocked from alternative forms of care by professionally licensed midwives.

To paraphrase a popular religious verse: “Who among you if his child should ask for bread, would give instead a stone?”

We must make sure our maternity care system does not unintentionally offer a stone while it claims to be offering a kindly extended helping hand.

The Bell that can’t be un-rung!

Given this historic backdrop, there is no mystery about the intimate connection between the politics of midwifery and those of the obstetrical profession. In the US, the problematic nature of contemporary obstetrics is the single most important predisposing fact in the ‘reinvention’ midwifery as a non-medical, community-based phenomenon.

The very existence of community-based midwifery care reflects a history that is already a century long in which healthy women remain unable to get the obstetrical profession to acknowledge the validity of their practical needs. Trained midwives are the safest and most acceptable maternity care alternative for a substantial segment of essentially healthy women who will otherwise be forced to choose between the Devil and the Deep Blue Sea —  between medically-unnecessary, unwanted, risky and expensive obstetrical interventions or unattended births by mothers who claim to be ‘surprised’ that their baby came so fast!

Midwifery is the archetypical “bell that can’t be un-rung”. Midwives will not shut up, or stop agitating for change until we are either dead or have successful rehabilitated our national maternity care system.

Here is the bottom line:

No healthy woman should ever has to choose between a midwife or an obstetrician, or between a home or a hospital in order to have a physiologically-managed normal labor and birth.

Period.

 part 4 ~ A possible win-win for mothers vs. obstetrics-as-usual

Historical overview

For centuries obstetrics was simply a general part of medicine. Since it did not include any advanced training in reproductive surgery, the skills of the average family practice doctor were not all that different from the typical practice of midwifery. In colonial American, childbirth services were split 50-50 between midwives and MDs. Before the late 19^th century, a doctor who attended births used to be called a “man-midwife”. If one of his patients needed a cesarean, he had to call in a gynecological surgeon.

But in the late 1800s Dr. J. Whitridge Williams, himself a gynecological surgeon and also professor of obstetrics at Johns Hopkins University Hospital,  insisted that the discipline of obstetrics should actually be a surgical (rather than medical) specialty. At the time, there was a highly contentious rivalry  going on between the discipline of obstetrics and gynecology. In discussing this professional conflict Dr. Williams commented that:

“ … gynecology and obstetrics are too sharply divided and are conducted upon too practical a basis to give ideal results. 

The progressive gynecologist considers that obstetrics should include only the conduct of normal labor, or at most .. cases that can be terminated without radical operative interference, while all other conditions should be treated by [the gynecologist] – in other words, that the [work] of the obstetrician should be [limited to] that of the man-midwife.”

To eliminate detrimental rivalry and economic completion and better promote the interests of both disciplines, it was decided that the two professions join forces to form a single combined surgical specialty referred to as “ob-gyn”. Dr. Williams was the perfect choice to arrange the forced marriage between these rival groups. His first position after graduating from medical school was to set up the gynecological surgery departmentin 1893 for the new Johns Hopkins University Hospital. Still employed by Johns Hopkins, Dr. Williams was appointed as  associate professor of gynecology a year later and served a two-year term as vice-president of the American Gynecological Society in 1903-04.

After being promoted to chief of obstetrics at Johns Hopkins, Dr. Williams wrote his classic obstetrical textbook “Williams Obstetrics”, first published in 1903. By the times he was appointed Dean of the School of Medicine in 1911, the medical speciality of obstetrics and surgical speciality of gynecology had been providing care as the hybrid surgical specialty of obstetrics and gynecology for more than a decade. The historical process for providing childbirth services as a cooperative venture between women and their family doctors or midwives was unilaterally phased out, as modern medicine’s latest speciality — obstetrics and gynecology — was advanced as the safer and more modern way to have a baby.

Between 1900 and 1910 the traditional practice of obstetrics, which had focused on the individualized needs of each childbearing woman, was dramatically (some might say drastically) re-congiured. The classical philosophy of ‘respectful restraint’ (i.e. Mother Nature knows best) was replaced by an unbridled enthusiastic for new ideas and new ways of thinking.

This included a very negative definition of  female reproductive biology that saw childbearing women as the helpless victims of an inherently defective, even pathological process of so-called ‘normal’ childbirth. Physicians who aggressively intervened were seen as cutting-edge leaders. Newspapers reported that normal pregnancy was now considered to be a “nine month disease requiring a surgical cure“.

From this perspective, only benefit was to come from interventions that shortened the length of labor. This particularly applied to surgical procedures that reduced the ‘exposure’ of the fragile fetal skull to the potentially harmful maternal pushing efforts of 2nd stage labor. To protect the mother’s delicate vaginal and perineal tissues from being damaged by the baby’s hard and relentlessly advancing head, the routine use of episiotomy and forceps were recommended.  Official concern for the mother’s perineum was best characterized by a famous 20th century obstetrician. He described spontaneous birth to be about “as natural as falling on a pitchfork”!

Obstetrical management and surgical delivery as the standard of care for normal childbirth represents the most profound change in childbirth practices in the history of the human species.

Labor was a heavily medicalized process under the care of hospital nurses. Newly hospitalized women were immediately given powerful injections of narcotics and the Twilight Sleep drug scopolamine. The purpose of Twilight Sleep was to produced amnesia, but scopolamine also was an hallucinogenic. Over the many hours of labor, women received multiple doses of both drugs and could not remember anything that happened while under their influence. When women began to push, they were moved by stretcher to the ‘delivery’ room, which was essentially an obstetrical operating room.

The conduct of normal vaginal birth by ob-gyn specialists was considered to be a new surgical procedure called “the delivery”. Like other kinds of operations, it required that the patient be anesthetized.

Dr. Williams was very proud to announce in 1912 that:

“in Johns Hopkins Hospital no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.” [Twilight Sleep: Simple Discoveries in painless childbirth” p. 67]

The new surgical standard for normal birth included general anesthesia, episiotomy, delivery of the baby with forceps, manual removal of the placenta, and suturing of the perineal incision.

This was followed by a mandatory separation of mother and baby for the first 12 hours as L&D nurses watched while the mother recovered from anesthesia, and nursery nurses monitored the new baby. Between the amnesic drugs received during labor and being rendered unconscious during the birth, many women described a bizarre and disturbing feeling of “blankness” where their experience of the birth of their baby should have been.

Unfortunately, these obstetrical protocols were all non-negotiable. As standard fare in every hospital, the laboring woman could not decline any procedure or drug, or any have any say whatsoever as to what was (or wasn’t) done to her. Even if a new mother remembered being mistreated or having an unexplained complication, no one would believe her, after all she’d been medicated with narcotics and hallucinogenic drugs and could never be a creditably witness on own behalf. This was important, as no husbands or other family member were ever allowed behind the swinging double doors to the labor ward that declared in big black letters: “Authorized Personnel Only”.

But the most important issue was how mothers and babies were being systematically harmed by these heavily medicalized obstetrical routines. Childbirth-related deaths of American mothers in the 1930s were orders-of-magnitude higher than maternal mortality rates (MMR) for Sweden and other European countries at the turn of the previous century (1900). Neither the narcotized labor patient nor the general public understood how risky these medical interventions and invasive procedures were when used routinely on a healthy population. Known side-effects and drug reactions from one intervention often required the use of more invasive procedures that resulted in a cascade of complications and sometimes ended in a preventable death for mother or baby.

Twilight Sleep drugs triggered a near psychotic-break in many laboring women. To keep such women from crawling out of bed, falling, attacking other patients or biting the nurses, heavy leather restraints were used tie them down on their back to the four corners of the bed frame. Unfortunately, keeping a mother-to-be flat on her back throughout the entire labor was the most painful position for her and also inferred with blood flow to the placenta, which causes fetal hypoxia (i.e. oxygen deprivation).

The use of forceps often damaged the mother’s pelvic structures. One particularly awful complication was an ‘obstetrical fistula’ — an abnormal opening between a new mother’s vagina and either her bladder or rectum that left her permanently incontinent of urine or stool. Before modern surgical repairs, this sentenced these new mothers to life as a social outcast.

The use of forceps often caused neurological damage to the baby. Narcotics from the laboring mother’s blood stream that transferred to the unborn baby during labor often prevented the baby from breathing after it was born. As an L&D nurse during the late 1960s, I witnessed narcotic-related fatal respiratory depression caused the death of many otherwise healthy newborns. As late as 1960, the general anesthesia routinely given to mothers during delivery was listed as the third most frequent cause of maternal death.

While the obstetrical profession continue to ascribe to “more is better”, the conclusions of the 1931 White House Conference on Child Health and Protection were just the opposite. In a report published in 1932 (Reed), the care of midwives was specifically praised because they refrained from interfering in the normal biology of childbirth:

“. . .that trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief . . . is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” (emphasis in original)

The book “Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950“ [Irvine Loudon; 1992] reported that:

“the risk of dying in childbirth in 1863 and 1934 were virtually identical. The high death rate was the result of lax antiseptic practices and poorly trained [physician] birth attendants who engaged in unnecessary and dangerous obstetrical interventions, especially forceps deliveries.

This fact became evident when national differences were taken into account. Loudon found that in 1935 the rate of obstetrical interference in Holland was 1%  and in New York 20%. When interference occurred, the death rate due to sepsis (infection) was 40 per 10,000 births, while the rate for spontaneous deliveries was 4 per 10,000.”

By the 1950s some L&D nurses began to criticize the obstetrical interventions being used routinely across the country as dangerous and contributing to other abusive practices, such as tying women to their beds and slapping them if they became upset. A few of these nurses were willing to provide whistle-blower information to popular women’s magazine.

 The Ladies’ Home Journal kicked things into high gear in 1958 with an article called  called “Cruelty in Maternity Wards“. Their account of the “tortures that go on in modern delivery rooms” triggered a flood of stories by other women who claimed: “The whole thing is a horrible nightmare”.  A nurse from Canada wrote: “I’ve seen patients with no skin on their wrists from fighting the straps.” A woman from Detroit thought the answer was to “… let a few husbands in the delivery rooms and let them watch what goes on there. That’s all it will take — they’ll change it!” 

The obstetrical profession’s reaction to this public outcry was simply to stonewall. Obstetricians insisted that lay people just didn’t ‘understand’ and were misinterpreting events recounted by mothers and L&D nurses. Representatives of the ob-gyn lobby focused on women’s magazines in general – what hubris for a magazine reporter claim to know more than a specialist in the field of obstetrics?

However, there was always a small minority of women who gave birth quickly, before they could be medicated with Twilight Sleep drugs and had vivid and intact memories of disturbing treatment. L&D nurses never got any of those “happy pills”, so nothing was wrong with their memories either. When these women were collectively asked: “Who are you going to believe? us and our obstetrical lobbyists, or your own lying eyes?” the two-fold answer was simple enough:

{1) the routine use of obstetrical intervention in healthy women during normal labor and birth was neither harmless nor helpful as the ob-gyn profession had always insisted

{2} obstetricians as a class preferred to remain clueless to these problems

From many different perspectives the inescapable conclusion was that contemporary obstetrics as an “expert” system was failing society in the very area it was supposed to have the most mastery and expertise – that is, preserving the health of already healthy mothers and babies.

Part 3 –Turning a backlash into effective political action

Reference: Obstetrics and Midwifery ~ Antiquity and the Medieval and Early Modern Period  http://www.faqs.org/childhood/Me-Pa/Obstetrics-and-Midwifery.html

Loudon, Irvine. 1992. Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950. Oxford: Clarendon Press.

What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present – Donald Caton, M.D.

Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth – Mark Sloan, M.D.

Deliver Me From Pain: Anesthesia & Birth in America – Jacqueline Wolf

By faith Gibson, LM, CPM ~ former L&D nurse, mother, grandmother, childbirth educator, birth activist, professional community midwife, and a person who is never afraid to hope for a better future

Healthy women with normal pregnancies living in developed countries generally have no reason to worry about the basic safety of normal childbirth. Since pregnancy is such an intimate and internal experience for them, the parturient women inevitably see giving birth as something they are intimately involving in doing, as opposed to something done to them or for them by others.

From their perspective, advancing these goals is simple and straightforward: They want to be surrounded by knowledgable, trusted and familiar people who are able and willing to actively support them during the normal biological process of pregnancy and childbirth. To a healthy woman, the quality of her physical and emotional experience during vhildbirth and the broad social aspects of pregnancy and parturition are of profound and long-lasting significance.

It is the coming together of these factors that turns a couple into parents, and makes the threesome of mother, father and new baby into a new family.

Tradition midwifery (lay and direct-entry/non-nurse) in California in the early 1970s was originally the progeny of the new birth education movement. These two budding social movements were a political backlash triggered and fueled by the systematic refusal of the obstetrical profession to acknowledge and support the voiced needs of healthy childbearing women. What they were asking for, but not getting, was normal and non-interventive care before, during and after normal childbirth.

There has been a dramatic and century-long mismatch between the expectation of society and what the obstetrical profession is actually offering. During labor, healthy women need and want maternity care providers who support them in practical ways.

However, obstetricians, as trained surgeons, don’t see their professional role to have anything to do with the mother’s experience of biologically normal childbirth. The job of ob-gyn doctors is to assure that both mother and baby are alive and able to leave after a few days in the hospital. Realistically, the obstetrical profession is not a dependable source of assistance in this regard.

Nontheless the experience of labor is a very important for most childbearing women unless she is havinf a complication. Whenever a pregnant woman is unfortunate enough to have medical problems or a serious complication, her attention is entirely focused the obstetrical expertise of her doctors. But this is not a typical, since 85% of term pregnancies reside inside healthy women.

A comprehensive maternity care system must address the needs of all categories of childbearing families. Certainly those facing serious problems deserve all the help society can provide, but the vast majority of the childbirth population is healthy. Our maternity care system must effectively address the very different set of issues experienced by these healthy childbearing families.

What most healthy women want from their professional birth attendants is direct, specific, and something first-time mothers (naively it seems) fully expect to receive — the full time presence of their doctors while they are in active labor, when they give birth and the first hours after their baby is born.

The new-mother/new-baby period is also extraordinarily important to healthy women. Having just finished the reproductive equivalent of the Boston Marathon, a new mother expects and deserves to be congratulated on having won an Olympic gold for her perseverance and hard work, and praised for such a great outcome (every newborn baby is cute!).

During this first hour or so, other important physical, emotional and sociological issues require the careful attention of her birth attendants. The new mother should be made warm and comfortable, given food and drink and introduced to her first breastfeeding experience. This is the time and place that a newly delivered woman begins the lengthy, often stressful process of adapting to her new mothering role.

With the new baby safely in her own arms (not in a fancy baby warmer in a far corner of the room where she can’t see or touch her new infant!), she and her husband/baby’s father and/or other significant family members begin to bond with their newborn as a newly cohesive unit. She needs and wants familiar and trusted faces in the room to witness and remember this once-in-a-lifetime miracle for her and her family. For some strange reason, women universally expect that their birth attendant will be one of these ‘familiar and trusted faces’.

It is a real shock for first-time mothers when they discover that the ob-gyn doctor they expected to be present during labor did not actually show up until just a few minutes before the baby was born. After the placenta came out, and perhaps a few stitches were placed, that same doctor quickly disappeared again while their baby was only minutes old. Like a spurned lover, this is a disappointment that many new mothers don’t get over easily. They subsequently speak very cynically about their experience and are often moved to seek out the services of a midwife when they get pregnant the next time.

Part 2: Historical Overview

This is a word-for-word comparison between the 2006 legal Standard of Care and the 2014 informal “guidelines” as edited by the MBC by strike-throughs to conform with AB 1308’s requirements.

This included deleting all mention of a childbearing woman’s autonomy or her ethical right of self-determination, and a midwife’s ethical duty to inform, advocate for and protect these rights for childbearing women under her care.

MEDICAL BOARD OF CALIFORNIA
May 2014

PRACTICE GUIDELINES FOR
CALIFORNIA LICENSED MIDWIVES

Annotated by faith Gibson, LM
Red = text added by MBC
Blue = text retained by the MBC that to some degree acknowledges or supports ethical practices

STRIKE-THRU – DELETED BY THE MBC per AB 1308

The California licensed midwife is a professional healthcare practitioner who offers primary care to healthy women and their normal unborn and newborn babies throughout normal pregnancy, labor, birth, postpartum, the neonatal and inter-conceptional periods.

I. PURPOSE, DEFINITIONS & GENERAL PROVISIONS

1. This document provides a framework to identify the professional responsibilities of licensed midwives, and permit an individual midwife’s practice to be rationally evaluated to ensure that it is safe, ethical and consistent with the professional practice of licensed midwifery in California. However, these practice guidelines are not intended to replace the clinical judgment of the licensed midwife.

Sources and documentation used to define and judge professional practice include but are not limited to the following:

1. The international definition of a midwife and the midwifery scope of practice
2. Customary definitions of the midwifery model of care by state and national midwifery organizations, including the Licensed Midwifery Practice Act of 1993 and all it amendments (Business and Professions Code Sections 2505, et seq.)
3. Standards of practice for community midwives as published by state and 
national midwifery organizations
4. Philosophy of care, code of ethics, and informed consent policies as published by state and national midwifery organizations
5. Educational competencies published by state and national direct-entry 
midwifery organizations

B. The California licensed midwife maintains all requirements of state and, where applicable, national certification, while keeping current with evidence-based and ethical midwifery practice in accordance with:

1. The body of professional knowledge, clinical skills, and clinical judgments described in the Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice

2. The statutory requirements as set forth in the Licensed Midwifery Practice
Act of 1993 (“LMPA”), all amendments to LMPA and the Health and Safety Code on birth registration.

3. The generally accepted guidelines for community-based midwifery practice as published by state and national direct-entry midwifery organizations

C. The California licensed midwife provides care in private offices, physician offices, clinics, client homes, maternity homes, birth centers and hospitals. The licensed midwife provides well-women health services and maternity care to essentially healthy women who are experiencing a normal pregnancy. An essentially healthy woman is without serious pre-existing medical or mental conditions affecting major body organs, biological systems or competent mental function. An essentially normal pregnancy is without serious medical complications affecting either mother or fetus, and is consistent with the definition set forth under Business and Professions Code Section 2507(b)(1). [text in RED added by MBC 5-2014]

D. The California licensed midwife provides the necessary supervision, care and advice to women prior to and during pregnancy, labor and the postpartum period, and conducts deliveries and cares for the newborn infant during the postnatal period. This includes preventative measures, protocols for variations and deviations from norm, detection of complications in the mother and child, the procurement of medical assistance when necessary and the execution of emergency measures in the absence of medical help.

E. The California licensed midwife’s fundamental accountability is to the women in her care. This includes a responsibility to uphold professional standards and avoid compromise based on personal or institutional expediency.

F. California licensed midwife is also accountable to peers, the regulatory body and to the public for safe, competent, ethical practice. It is the responsibility of the licensed midwife to incorporate ongoing evaluation of her/his practice, including formal or informal sources of community input. This includes but is not limited to the licensed midwife’s participation in the peer review process and any required mortality and morbidity reporting. The results of these individual evaluations can be distributed to influence professional policy development, education, and practice.

G. The California licensed midwife is responsible to the client, the community and the midwifery profession for evidence-based practice. This includes but is not limited to continuing education and on-going evaluation and application of new information and improved practices as recommended in the scientific literature. It may also include developing and dispersing midwifery knowledge and participating in research regarding midwifery outcomes.

H. The California licensed midwife uses evidence-based policies and practice guidelines for the management of routine care and unusual circumstances by establishing, reviewing, updating, and adhering to individualized practice policies, guidelines and protocols appropriate to the specific setting for a client’s labor and birth and geographical characteristics of the licensed midwife’s practice. Practice- specific guidelines and protocols are customarily implemented through standard or customized chart forms, informed consent and informed refusal documents and treatment waivers (including the consent required in Business and Professions Code Section 2508), other formal and informal documents used routinely for each area of clinical practice, including but not limited to the antepartum, intrapartum, postpartum, newborn periods and inter-conceptional periods.

I. The licensed midwife’s policies, guidelines and protocols are consistent with standard midwifery management as described in standard midwifery textbooks or a combination of standard textbooks and references, including research published in peer-review journals.

Any textbook or reference which is also an approved textbook or reference for a midwifery educational program or school is considered an acceptable textbook or reference for use in developing a midwife’s individual policies and practice guidelines. When appropriate or requested, citations of scientificsource should be made available for client review.

J. The licensed midwife may expand her skill level beyond the core competencies of her training program by incorporating new procedures into the individual midwife’s practice that improve care for women and their families. It is the responsibility of the licensed midwife to:4.

1. Identify the need for a new procedure by taking into consideration consumer demand, standards for safe practice, and availability of other qualified personnel.

2. Ensure that there are no institutional, state, or federal statutes or regulations that would constrain the midwife from incorporation of the procedure into her practice.

3. Be able to demonstrate knowledge and competency, including:

a) Knowledge of risks, benefits, and client selection criteria.

b) Having a process for acquisition of required skills.

c) Identifying and managing complications.

d) Employing a process to evaluate outcomes and maintain professional competency.

4. Identify a mechanism for obtaining medical consultation, collaboration, and referral related to each new procedure.

II. A BRIEF OVERVIEW OF THE LICENSED MIDWIFE’S DUTIES AND SPECIFIC RESPONSIBILITIES TO CHILDBEARING WOMEN AND THEIR UNBORN AND NEWBORN BABIES

A. The California licensed midwife engages in an on-going process of risk assessment that begins with the initial consultation and continues throughout the provision of care. This includes continuously assessing for normalcy and, if necessary, initiating appropriate interventions including consultation, referral, transfer, first-responder emergency care and/or emergency transport.

B. Within the midwifery model of care, the licensed midwife’s duties to women and babies include the following individualized forms of maternity care:

1. Antepartum care and education, preparation for childbirth, breastfeeding and parenthood.
2. Risk assessment, risk prevention and risk reduction.
3. Identifying and assessing variations and deviations from normal and detection of abnormal conditions and subsequently communicating that information to the woman and, when appropriate, to other health care providers and emergency responders.
4. Maintaining an individual plan for consultation, referral, transfer of care and emergencies.
5. Evidence-based physiological management to facilitate spontaneous progress in labor and normal vaginal birth while minimizing the need for medical interventions.
6. Procurement of medical assistance when indicated.
7. Execution of appropriate emergency measures in the absence of medical help.
8. Postpartum care to mother and baby, including counseling and education.
9. Maintaining up-to-date knowledge in evidence-based practice and proficiency 
in life-saving measures by regular review and practice.
10. Maintenance of all necessary equipment and supplies, and preparation of 
documents including educational handouts, charts, informed consent & informed refusal documents [added by MBC 5-2014] (including the consent required in Business and Professions Code Section 2508), birth registration forms, newborn screening, practice policies, guidelines, protocols, and, morbidity and mortality reports and annual statistics

III. GUIDELINES FOR COMMUNITY-BASED MIDWIFERY


ONE: The licensed midwife is accountable to the client, the midwifery profession and thepublic for safe, competent, and ethical care.

TWO: The licensed midwife ensures that no act or omission places the client at unnecessary risk.

THREE: The licensed midwife, within realistic limits, provides continuity of care to the client throughout the childbearing experience according to the midwifery model of care.

FOUR: The licensed midwife respects the autonomy of the mentally competent adult woman by working in partnership with her and recognizing individual and shared responsibilities. The midwife recognizes the healthy woman as the primary decision maker throughout the childbearing experience.

FIVE: The licensed midwife upholds the client’s right to make informed choices about the manner and circumstance of pregnancy, and childbirth, and facilitates this process by providing complete, relevant, objective information in a non- authoritarian and supportive manner, while continually assessing safety considerations and risks to the client, informing her of same.

SIX: [added by MBC 5-2014] The licensed midwife immediately refers the client to a physician, as required by law, if at any point during a pregnancy, childbirth, or postpartum care the client’s condition deviates from normal.

SEVEN: The licensed midwife confers and collaborates with other health care professionals, including other midwives, as is necessary to professionally meet the client’s needs. When the client’s condition or needs exceed the midwife’s scope of practice or personal practice guidelines, the licensed midwife consults with and refers or transfers the client to a physician or other appropriate health care provider.

EIGHT: Should the pregnancy deviate from normal and primary care be transferred to a physician, the licensed midwife may continue to counsel, support and advise the client at her request.

NINE: The licensed midwife maintains complete and accurate health care records.

TEN: The licensed midwife ensures confidentiality of information except with the client’s consent, or as required to be disclosed by law, or in extraordinary circumstances where the failure to disclose will result in immediate and grave harm to the client, baby or other immediate family members or professional care providers.

ELEVEN: Where geographically feasible, the licensed midwife makes a good faith effort to ensure that a second midwife, or a qualified birth attendant certified in neonatal resuscitation and cardiopulmonary resuscitation, is available during the delivery.

TWELVE: The licensed midwife orders, uses or administers only thosedrugs, supplies, devices and procedures that are consistent with the licensed midwife’sprofessional training as described in 16 CCR 1379.30, community standards and the provisions of LMPA and does so only in accordance with the client’s informed consent.

THIRTEEN: The licensed midwife orders, performs, collects samples for, or interprets those screening and diagnostic tests for a woman or newborn which are consistent with the licensed midwife’s professional training, community standards, and provisions of the LMPA, and does so only in accordance with the client’s informed consent.

FOURTEEN: The licensed midwife participates in the continuing education and evaluation of self, colleagues and the maternity care system.

FIFTEEN: The licensed midwife critically assesses evidence-based research findings for use in practice and supports research activities.

IV. CRITERIA FOR CLIENT SELECTION [originally “part A”]

Criteria for initial selection of clients for community-based midwifery care assumes:

• Healthy mother without serious pre-existing medical or mental conditions
• History, physical assessment and laboratory results within limits commonly 
accepted as normal and [added by MBC 5-2104] consistent with Business and Professions Code Section 2507(b)(1) with no clinically-significant evidence of the following, including but not limited to:

1. cardiac disease
2. pulmonary disease
3. renal disease
4. hepatic disease
5. endocrine disease
6. neurological disease
7. malignant disease in an active phase
8. significant hematological disorders or coagulopathies
9. essential hypertension (blood pressure greater than 140/90 on two or more 
occasions, six hours apart)
10. insulin-dependent diabetes mellitus
11. serious congenital abnormalities affecting childbirth
12. family history of serious genetic disorders or hereditary diseases that may impact on the current pregnancy
13. adverse obstetrical history that may impact on the current pregnancy
14. significant pelvic or uterine abnormalities, including tumors, malformations, or invasive uterine surgery that may impact on the current pregnancy
15. iso-immunization
16. alcoholism or abuse
17. drug addiction or abuse
18. positive HIV status or AIDS
19. current serious psychiatric illness
20. social or familiar conditions unsatisfactory for community-based birth services
21. other significant physical abnormality, social or mental functioning that affects pregnancy, parturition and/or the ability to safely care for a newborn
22. other as defined by the licensed midwife 

NOTE: The “Client Selection Criteria” in the original (52-page) California College of Midwives’s Standard of Care was paired with a “Part B”.  

It provided for physician consultation or referral for clients with minor pathologies or other conditions listed above that were not likely to affect the outcome pregnancy, normal childbirth, or the neonate, while also acknowledging the right of childbearing woman to decline such advise.

I included Section B only for its informative value only, since it never was part of the 2006 Standards adopted by the OAL or the MBC’s May 2014 revised & renamed “Practice Guidelines”.

I indented this section to make this distinction clear 

IV-B ~ Obstetrical Consultation or Referral

(Taken from the original, 52-page CCM version)

When a prospective client has pre-existing medical issues, the midwife routinely consults with a physician, or refers the perspective client to a physician for evaluation prior to determining if the pregnant woman is an appropriate candidate for community-based birth services:

1. Physical and mental conditions or diseases of clinical significance that require ongoing use of medical treatment or Rx medications
2. Family history of clinically-significant genetic disorders, hereditary disease, or congenital or genetic anomalies likely to affect the pregnancy or unborn/newborn baby
3. History of 3 or more sequential spontaneous abortions and/or 2 or more late miscarriages
4. History of preterm birth of VLBW infant, unexplained stillbirth, or neonatal mortality associated with maternal disease, a GBS infected newborn, serious congenital or genetic anomalies
5. History of significant fibroids or uterine surgery involving an incision into its musculature
6. Previous unexplained antepartum or postpartum hemorrhage requiring transfusion in spontaneous labor (i.e., previous labor was not induced or augmented; previous PPH was a non-repeating pathology such as placenta previa)

This list is not exhaustive, as other medical or mental conditions not identified above may require medical evaluation before a client is accepted for community-based childbirth services.

Nor is the list meant to be an absolute contra-indications to midwifery care. There are circumstances in which fully informed parents have an ethical right to choose physiologically-managed childbirth in an OOH setting in spite of a specific identified risk factor. Examples include history of repeat miscarriages or previous Cesarean, family history of hereditary disease, or unexplained fetal or neonatal death, and other issues may continue to be possible but have a low probability of reoccurrence.

RETURN TO MAY 14th REVISION BY MBC

V. RISK FACTORS IDENTIFIED DURING THE INITIAL INTERVIEW OR ARISING DURING THE COURSE OF CARE

Wording as edited by MBC at Dec 5^th, 2013 Mfry Council meeting, & published May 2014

Responsibility of the Licensed Midwife

With respect to the care of a client with a significant risk factor as identified by the client selection criteria in section IV, other science-based parameters or physical examination, the licensed midwife shall inform the client about the known material risks and benefits of continuing with midwifery care relative to the identified risk factor and shall recommend to the client that her situation be evaluated by a medical practitioner and if appropriate, to transfer her primary care to a licensed physician who has current training and practice in obstetrics.

(by striking out of “medical practitioners”, it means LMs cannot refer to CNM, nurse-practitioner or PA)

Client’s Rights to Self-Determination

In recognition of the client’s right to refuse that recommendation as well as other risk- reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal.

If the licensed midwife appropriately documents the informed refusal in the client’s midwifery records, the licensed midwife may continue to provide midwifery care to the client consistent with evidence-based care as identified in this document and the scientific literature.

[added by AB 1308] With respect to the care of a client who deviates from a normal pregnancy as identified by the client selection criteria in section IV or other science-based parameters, the licensed midwife informs the client that her situation must be evaluated by a licensed physician who has current training and practice in obstetrics and gynecology.

If the physician determines that the client’s condition or concern has been resolved such that the risk factors presented by a woman’s disease or condition are not likely to significantly affect the course of pregnancy, the licensed midwife can continue to provide primary care.

The client should further be informed that unresolved significant risk factors will limit the scope of the midwife’s care to concurrent care with a physician, regardless of whether the woman has consented to care or refused care by a physician.

It is recognized that the client has the right to refuse the recommended referral; however, pursuant to the law, the licensed midwife cannot continue care. The licensed midwife will document refusal of the referral in the client’s record.

Like most Ca LMs, I received a notice from the Medical Board for the Interested Parties meeting at the MBC’s state offices in Sacramento on Oct 15th (1-4pm)

This event will set the tone for implementation of AB 1308 relative to:

(i) Any preexisting maternal disease or condition likely to affect the pregnancy.
(ii) Significant disease arising from the pregnancy.

Link to full text of Assembly Bill 1308

Background Information

The ONLY agenda items for the MBC’s  Interested Parties meeting are reviewing, discussing and proposing potential regulations to define B&P section 2507, lines (b),(1),(A),(i) and Section 2510 of the LMPA.

Section 2510 reads: If a client is transferred to a hospital, the licensed midwife shall provide records, including prenatal records, and speak with the receiving physician and surgeon about labor up to the point of the transfer. The hospital shall report each transfer of a planned out-of-hospital birth to the Medical Board of California and the California Maternal Quality Care Collaborative using a standardized form developed by the board.

Section 2507– relative language from lines (b),(1),(A),(i) reads:

(b) As used in this article, the practice of midwifery constitutes the furthering or undertaking by any licensed midwife to assist a woman in childbirth as long as progress meets criteria accepted as normal. (1) Except as provided in paragraph (2), a licensed midwife shall only assist a woman in normal pregnancy and childbirth, which is defined as meeting all of the following conditions:

(A) There is an absence of both of the following:

(i) Any preexisting maternal disease or condition likely to affect the pregnancy.

(ii) Significant disease arising from the pregnancy.

Short and long-term strategy for addressing these issues

First its important to ‘think big’ and think ‘long-term’. This is only the beginning of the a year long (or longer) regulatory process that only ends when the Office of Administrative Law (OAL) approves the ‘proposed’ regulation.

We have to remember that one of the most important things midwives and supportive childbearing families can do is to submit appropriately-targeted, high-quality written testimony before or at the regulatory hearings. By law,  all this material must be read and taken into consideration by the attorneys at OAL who decide whether or not the proposed reg is a lawful based on 6 legal requirement.

If we aren’t able to block unworkable policies and language during the “promulgation” process (i.e. what is proposed and voted on by the MBC) our next best hope is to be sure the OAL is fully and appropriate informed of the problems.

The second vital issue is for Ca LMs to be clear about the IP meeting’s agenda, which legally restricts us to just three topics.

Discussion at the October 15th meeting, as defined by its published “Agenda” is ONLY about lines (b),(1),(A),(i) in Sec 2507 and about 2710 (hospital reports for transfers by Ca LMs from OOH setting).

The October meeting is NOT going to address or even talk about the bigger and far more serious problems with language in AB 1308 requires LMs to “immediately” transfer care anytime during pregnancy, childbirth or PP that the client’s “condition” deviates from “normal“.

Relative to this provision, two facts are relevant.

Issue #1. In regard to health care, the concept ‘condition’ is like the word ‘temperature’ — everybody has a ‘temperature’, which is far different issue than having a fever (100.5 or greater).

Unless the word ‘temperature’ is defined by an adjective such as: “clinically significant elevation“, or in the case of “condition”, a ‘pathological, or clinically significant condition‘, they are both totally useless concepts from the standpoint of providing the necessary legal guidance required to be enforceable.

It is virtually impossible to  define this concept without coming back right to the idea of “pathological, or clinically-significant” condition.

At the heart of the phrase “clinically significant” is the vital distinction between “possible” and “probable”. A very large number of situations and ‘conditions’ carry within them a “possibility” of becoming pathological and resulting in a serious complication or worse. A very much smaller number of situations and conditions are associated with a high probability that a very serious complication or worse will occur.

A ‘clinically significant’ condition is one in which it is probable that a bad outcome will occur unless medical or surgical interventions are used.

Therefore a ‘significant’ medical condition implies a pathological state associated with the serious complications of childbearing likely to result in serious physical damage, disability or death for the parturient woman or her unborn or newborn baby.

The same linguist problem applies to the undefined concept of ‘normal‘.

Another easily-to-abused example that also has political implications is the undefined use of the word “qualified”. For most of the 20th century, the right to vote was limited in southern states by passing laws that restricted voting to “qualified” persons over a stated age. However these law usually didn’t define what made a person “qualified”.

This allowed any state official or county employees to define “qualified” as what ever they wanted it to be that particular day for that particular person or situation. For over a century, this undefined word was used to discriminate against the poor and ethnic minorities to keep them from voting.

In a contrasting example, there is a section in California Medical Practice Act that restricts the practice of medicine to “qualified” physicians. However, the MPA very specifically defines the concept  – a graduate from a MBC-approved medical school who holds a valid California state license to practice medicine that is in good standing.

Issue # 2 ~  Ca LMs are going to have to keep track of and report the specific nature and frequency of problems this language causes for us and our client families in preparation for finding a legislative or legal “remedy”.

I’ve been thinking about this for several months and have quite a few suggestions for strategies that are likely to be effective.

However, that is a conversation for another day.

A unified strategy for LMs & C-Fam @ the Oct 15th Meeting

1. The majority position by our State’s midwifery and consumer organizations, other supportive groups and individual midwives and families is that the MBC adopt into regulation:

The ‘Criteria for Client Selection‘ from the 2006 Standard of Care for California Licensed Midwives  (SCCLM), which was part “a” in the original regulation and part 2 which include VBAC protocols previously approved by ACOG as defining the issues in section 2507, lines (b),(1),(A),(i)

Here is the currently published language fro California Code of Regulations, Title 16:

This quote from Legislative Council Digest shows just how high the stake are, as it states that violation of the LMPA is a “crime” and then goes on to say:

“The bill would authorize the board to suspend or revoke the license of a licensed midwife for failing, when required, to consult with a physician and surgeon, to refer a client to a physician and surgeon, or to transfer a client to a hospital.”

Background info to support re-adoption of the Criteria for Client Selection from our previous Standard of Care/current MBC Practice Guidelines for Ca LMs:

Recent and definitive info on national birth certificate reporting of NNM in the Linked Birth/Death Data set AND the NNM rate averaged for the last 4 years of LMAR data (over 10,000 births with NNM rate for Ca LMs of 1.3 per 1,000)

CDC’s National Vital Statistics Report provides statistics for live births in all 50 states and territories . This includes the total number of live births, and birth-outcomes from mothers and babies by birth order, age of parents, ethnicity, gestational age and birth weight of the baby, plus an exhausting list of miscellaneous and esoteric data sure to put an ordinary mortal to sleep.

Birth certificate data also reports the total number and rate of vaginal births, Cesarean deliveries, inductions, other medical and surgical procedures (except for episiotomies) and number and rate of maternal and neonatal morbidity in the top five categories for both.

In 2012, the total number of live birth in the US and territories was 3,952,841 (3.9 million). However, the full set of statistical data (2003 revision of the national birth registration form) with reliable breakdown of medical data only includes information from the 38 reporting states & DC. That data set if only 3,412,436.

Data below on NSVD, C-section, place-of-birth, and category of birth attendant reflect information from this 38 states, which includes California.

The number of spontaneous vaginal births in 20102 was 2,171,651 (2.1 million) and 1,296,070 Cesarean surgeries were performed (1.3 million). Forceps and vacuum extraction were used in 117,022 births .

When operative vaginal deliveries are combined with the number of Cesareans performed, the total number of surgical deliveries in this subset of only 38 states is over 1.4 million (1,413,092), which is more significantly more than third of all births in the US.

Even this high number does not include episiotomy, which is surgical procedure in which a pair of sterile scissors are used to cut the childbearing mother’s perineum (i.e. the delicate isthmus of skin, subcutaneous fat and deep muscle that includes all the external and internal tissues between the woman’s vagina and rectum).

While our national nativity statistics do not at present collect statistics for this surgical procedure, other source identify that approx. 35% of childbearing women have an episiotomy performed, often as a preamble to the use of forceps or vacuum extraction.

The National Vital statistics Record also records both place-of-birth and category of birth attendant.

The total # of OOH births in 2012 was 53,635, which included:
35,184 in parents’ homes,
15,577 in birth centers,
2,424 in “other”
450 doctors offices

OOH” place of birth stats also record by category of birth attendant:
Non-nurse midwife — 22,957
Nurse midwives (CNM) — 16,040
“Other” — 2,352
Medical Doctors —2,352

However the NVSR does NOT record fetal or neonatal deaths.

In order to get neonatal mortality statistics the CDC’s “Linked Birth/Infant death Data Sets” must be used.

The most recent publication (Dce 18, 2013) reporting national statistics for neonatal mortality is for 2010. It includes most of the same type of data as the birth certificate, in that numbers and rates of neonatal deaths are also calculated based on demographic categories for the parents (age and ethnicity, etc) and gestational ages and birth weights for babies that died.

But unfortunately, NNM data does NOT pair or calculate mortality relative to either the planned or actual ‘place-of-birth’. Neither does it give NNMR by category of birth attendants (MD, CNM, LM, other, etc). No neonatal mortality data that is specific to planned OOH births for professional nurse and direct-entry midwives is available via birth or death certificate data sets.

The closest comparison of outcomes between hospital-based obstetrics and professional midwives providing care in OOH settings are national neonatal mortality statistics for the categories of gestational age @ term (37.0 to 42+ wks) and birth weight (over 2,500 grams). Birth certificate data includes congenital anomalies.

Midwives providing community-based (OOH) childbirth services to essentially healthy women don’t attend any OOH labor until the mother has completed 37 wks of pregnancy. In addition they generally transfer any pregnancy woman who fetuses has signs or symptoms of severe growth restriction. This means the vast majority of mothers whose babies are delivered by Ca LMs would be 37+ weeks of gestation, have babies weighing at least 2,500 grams.  By averaging the outcomes of these two categories, we get data that allows comparison of outcomes btw professional community-based midwifery care and hospital-based obstetrical management.

Using the final data for 2010 from the ‘linked birth-death data set’, the overall number and percentage of babies born that year in these two vital categories — term gestational age over 37.0 to 42+ wks, and all babies born with a birth weight over 2,500 grams — could be determined.

The annual total of live birth in 2010 was 3,999,386. Of those,  3,515,317, occurred after the term of pregnancy (37 wks thru 42+wks), which represents 88% of all births that year.

Within that subset of term-born babies, there were 8002 neonatal deaths reported or a NNMR of 2.3 (1:439)

There were 3,671,997 babies born who weighed more than 2,500 grams at birth or approx 89% of total. Within that subset of normal birth weight babies, there were 7,821 neonatal deaths or 1:469 for a NNMR per 1,000 of 2.1.

When averaged, the NNMR is 2.2 per 1,000 in the US

Statistics from the LMAR 2010 to 2013

The total number of mothers who began labor at home with the intention of having a planned OOH birth were 10,668. 

All neonatal mortality (including congenital anomalies incompatible with like) were 21 (1:505 births or 2:1000).

Excluding fatal birth defects, there were 14 neonatal deaths reported (1:762 or 1.3 per 1000) 

Data published by Childbirth Connection.org in its “What Every Pregnant Women Needs to Know About Cesarean Section” give the following statistical definitions of maternal-infant risk status:

Very high                    1 to 10 of every 10 mothers or babies
High                             1 to   9 of every 100
moderate                     1 to   9 of every 1,000
Low                              1 to   9 of every 10,000
very low                      1 to   9 of every 100,000 mothers or babies

This means the average NNM rate (excluding fatal congenital anomalies) for Ca LMs over the last 4 years (1.3 per 1,000) is “moderate” and in the same statistical category as the national nativity stats for pregnancy outcomes @ term (37+wks)

As reported in the Linked Birth/Death Data Set for 2010 (last year available), the average NNMR in the US is 2.2 per 1,000.

According to the definitions of risk identified above, the NMR rate for Ca LMs (at 1.3 peer 1,000) and the US rate @ 2.2 per 1,000 are both in the risk category judged to be “moderate”.

These statistics, which clearly establish the relative safety of professional care of LM in OOH setting as equivalently safe,  should be included as ‘written testimony’ when proposed regulations for Ca LMs are submitted for approval by the Office of Administrative Law (OAL).

Comparing morbidity and medical interventions

In addition to neonatal mortality, these is also a very substantial difference in the rate for the top five obstetrical interventions —