California College of Midwives

June 2013

… less likely to lose their babies before 24 weeks or give birth before 37 weeks.

 Women were happier with the care they received, had fewer epidurals, fewer assisted births, and fewer episiotomies

… care provided by midwives was more cost-effective during labour

…. researchers conclude that all women should be offered midwife-led continuity of care unless they have serious medical or obstetric complications

Maternity care that involves a midwife as the main care provider leads to better outcomes for most women, according to a systematic review published in The Cochrane Library.

Researchers found that women who received continued care throughout pregnancy and birth from a small group of midwives were less likely to give birth pre-term and required fewer interventions during labour and birth than when their care was shared between different obstetricians, GPs and midwives.

In many countries, including the UK and Australia, midwives act as the main providers of care for women throughout pregnancy, labour and birth.

In midwife-led care, there is an emphasis on normality, continuity of care and being cared for by a known, trusted midwife during labour. Midwife-led continuity of care is provided in a multi-disciplinary network of consultation and referral with other care providers.

This contrasts with medical-led models of care, where an obstetrician or family physician is primarily responsible for care, and with shared-care, where responsibility is shared between different healthcare professionals. There has been some debate about whether the midwife-led model of care is more effective.

The researchers reviewed data from 13 trials involving a total of 16,242 women. Eight trials included women at low risk of complications and five trials included women at high risk of complications. They looked at outcomes for mothers and babies when midwives were the main providers of care, compared to medical-led or shared care models.

When midwives were the main providers of care throughout, women were less likely to give birth before 37 weeks or lose their babies before 24 weeks. Women were happier with the care they received, had fewer epidurals, fewer assisted births, and fewer episiotomies. An episiotomy involves making a surgical incision to reduce the risk of a tear.

In addition, women who received midwife-led care were no more likely to have a caesarean birth, but they were in labour for about half an hour longer on average.

Based on these results, the researchers conclude that all women should be offered midwife-led continuity of care unless they have serious medical or obstetric complications.

“Women should be encouraged to ask for this option,”

said lead researcher Jane Sandall of the Division of Women’s Health at King’s College London in London, UK, who led an interdisciplinary team of researchers from Sheffield Hallam University, The University of Warwick and National University of Ireland Galway.

“Policymakers in areas of the world where health systems do not provide midwife-led care should consider the importance of midwives in improving maternity care and how financing of midwife-led services can be reviewed to support this.”

Five studies considered the cost of midwife-led compared to shared care. While care provided by midwives was more cost-effective during labour, the results for postnatal care were inconclusive. “There was a lack of consistency in the way that maternity care cost was estimated in the studies, but there seemed to be a trend towards a cost-saving effect of midwife-led care,” said Sandall.

Dear Midwives,

As a midwife who has been practicing since the 1970s, I would like to first express my appreciation to Sarah Davis and Constance Rock for their extraordinary dedication to our profession and the families we serve, as well as Faith Gibson and the members of the Midwifery Advisory Council for the countless hours invested in representing our concerns to the Medical Board of California (MBC).

This legislative year we are faced with an unprecedented opportunity for needed change in California.  If we unite to support CAM in these efforts, the boulder that has finally begun to roll down the mountainside can and will continue to gain momentum beyond this “tipping point.”

There are relatively few midwives still practicing in California who can remember the 1970s and 1980s “witch hunts” conducted by the Board of Medical Quality Assurance (the predecessor to the Medical Board of California) and the Board of Registered Nursing, both of which initiated multiple investigations against pre-licensure midwives and the few RNs who were practicing midwifery legally under standardized procedures.

It has been well said that there is no such thing as “marking time,” that we are either moving forward or moving backward.  Standing still is just an illusion we indulge in.

Some California midwives have taken up the rallying cry that it is time to kill this bill.  AB 1308 may not be ideal but, as one who went through the midwifery investigations thirty years ago, AB 1308 is 150% better than wondering which client will be the one that results in your arrest–even when no adverse outcome or sentinel event is involved.  (I was investigated twice for births I did not even attend, and was one of just a few RNs who managed to keep my license during those years.)

ACOG, who initiated this bill during this legislative session, is finally willing to delete the physician supervision clause in exchange for our attendance at normal births, defined as vertex singletons between 37 and 42 weeks gestational age, a definition that covers a sizable majority of the birthing population.

If we refuse to move forward on this issue during the current legislative session, do any of you realistically imagine that we can just begin the process again next year where we left off? That we can “mark time” where we currently stand?  If the Department of Consumer Affairs (now designated as “large and in charge” over MBC practice violations) decides to pursue physician supervision, challenging the ruling of the Alison Osborn case on which we have depended, such a policy will once again mean that 100% of our clients put us at risk.  A return to the 1980s is not unimaginable to those of us who went through it. It was a frightening time, personally and professionally.

Some midwives are angry over the specified definition of normal pregnancy within AB 1308. While my heart goes out to women who desire homebirth with breech babies, multiples, preterm births, 42 week pregnancies, and prior uterine surgery, the data simply do not support midwives assisting higher-risk births at home.

One study by a well-known homebirth-friendly physician researcher is available on the GentleBirth site here:

http://www.gentlebirth.org/archives/hbMehlMadrona.html.

Recently one of our midwifery students challenged me on this matter recently, saying:

“But Marla, standards of care change.”  

I told her that attitudes may come and go but that the widely accepted standards of care for safe homebirth have remained the same for several decades: one baby, head down, with a mother in essentially good health with a favorable medical and obstetrical history.

If you doubt this, go back and read the books that guided those of us who began attending births during this country’s midwifery and homebirth renaissance. Read Raven Lang’s Birth Book, published in 1972.  Find a copy of Home Birth: A Practitioner’s Guide to Birth Outside the Hospital by Sagov, et al., published in 1984. Read the original version of Suzanne Arms’ Immaculate Deception.

Even the “ancient” fifth edition of Myles’ Textbook for Midwives lists pre-eclampsia, mulitiples, polyhydramnios, previous cesarean, preterm labor, and breech presentation as “contraindications to home confinement.” There is a reason that these risk screening criteria exist, and it is not because they are simply traditional or have never been examined or tested.  These criteria exist and persist because they have value.  They support physiologic birth and work very well in out-of-hospital settings.

There is currently a certain amount of agitation over our California Midwifery Standards of Care and precisely what AB 1308 might require in terms of physician “permission.” With all that the Medical Board has before it now and in the foreseeable future, it seems very unlikely that the Standards of Care that have been accepted and approved by the MBC since 2005 will suddenly be overhauled by the demands of AB 1308.

These standards were originally authored by Faith Gibson, LM and were then reviewed by Licensed Midwives who volunteered to meet in committees to think the standards through carefully, considering the ramifications for LMs across the state.  We deliberated over minutiae in meetings for several weeks, even creating considerations for “what happens if the law should change?” Many of us were involved.

So if the strictest standards are applied and you can “only” attend 85% of the births that occur in the State of California, is that so terrible?  Isn’t this better than having 100% of the women whose births you attend put you and your license at risk?  As one LM aptly observed, “I may not be able to so easily attend VBACs in the future, but I will certainly be able to help a lot more first-time moms avoid a primary cesarean.”

As Licensed Midwives, it is part of our responsibility to exercise caution and discernment regarding our clients’ risk status following guidelines from evidence-based practice.  We can and should assist mothers who do not fit long-accepted screening criteria to birth where conditions are more likely to result in favorable outcomes.

If you want to discuss possibilities, consider a future in which more California LMs have hospital privileges and can actually assist their clients in that setting when transfer becomes necessary. Two LMs in California already attend births in hospitals. Nothing in the law prohibits us from doing so.

I have practiced in three states over the course of my career: Texas, Utah, and California.  I have been very politically active during my entire midwifery career (with good reason) and have observed and been involved with the legislative efforts of midwives in several states.  I have witnessed what happens when just one midwife’s failure to apply appropriate risk screening to her out-of-hospital clients results in an adverse outcome.  I have seen how a single decision made by one midwife affects every other midwife in the state and the women and babies she serves.

Like it or not, legislators and the general public often extrapolate one midwife’s results to the profession generally.

It will be interesting to see what effect an unlicensed Utah midwife’s decision to attend a VBA3C at home will have on midwifery in the last remaining state in the U.S. to have optional licensing for midwives: http://www.sltrib.com/sltrib/news/56483765-78/halta-charges-according-newborn.html.csp

If you are scandalized by the circumstances outlined in this article, ask yourself these questions: Was it this mother’s right to birth at home?  Was it the midwife’s right to attend her birth as an unlicensed midwife?  Do you think the midwife should have exercised an element of risk screening? Should a scope of practice (e.g., no misoprostol, no vacuum extractors) apply to homebirths in this situation?  And if so, where do you, personally, draw the line–and why?  What should a scope of practice look like?

I have to say that, in comparison to the standards of practice defined for midwives in many other states, we frankly have a pretty good thing going in California.

When I moved to Texas in 1979, I became heavily involved in midwifery politics and legislation. Holly Scholles (past president of MEAC and now residing in Oregon) and I worked together to form the Association of Texas Midwives.  In response to increasing concerns about direct-entry midwifery practice in the state, we also helped author a bill with Rep. Hector Uribe based on Informed Choice that passed and became the Texas Midwifery Practice Act.

Our “playbook” was Chapter 34 of Volume 2 of a series of books by the National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC).  The chapter was written by Alan Star Solares and was called “Midwifery Licensing: Pitfalls, Problems, and Alternatives to Licensing.”

Interestingly, years later Solares stated that his utopian view of non-licensure had changed as, without a defined midwifery scope of practice and standards of care, it had become very clear that the world of healthcare and insurance would continue to lock out direct-entry midwifery and do its level best to confine the practice to the 1%. We have an unprecedented opportunity in California to move beyond that present reality and set a precedent for midwifery practice in other states–but not if we kill this bill.

A midwife who taught me in the 1970s said recently,

“I have attended more than 4,000 births in my career so far. When a woman comes to me asking for an exception to the Standards of Care, I think about all the women and babies I have helped and all those I can assist in the future.  I have to think about how making an exception ‘just this once’ might change everything for all my future clients and their babies, as well as for other midwives.  Sometimes we just get to say ‘No.'”

If you have made it this far, I hope that this post provides historical perspective.  We midwives are passionate for our clients and for the services that we can provide. Without that passion, we would have perished long ago.

Please consider working together to support our CAM leaders politically, emotionally, and financially for the outstanding work they have done on AB 1308 during this legislative session.

We can also express our gratitude for the generally thankless work that has been done by the members of the Midwifery Advisory Council and all those who came before us. We can and will make a difference, with the opportunity to serve more women and babies than ever before.

We need to unite now to make that happen.

The following update on AB 1308  was written by: Adeola Adeseun, Treesa Mclean, Jennifer Heystek, Tanya Smith-Johnson and Louis Heystek

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This it to update you on the status of our efforts to remove physician supervision of licensed midwives from California law, and to urge you to actively support AB1308, which, despite its limitations, represents a historic victory for families that want and deserve access to midwifery care.

Earlier this year, CFAM launched a statewide, grassroots effort to make one critical change to California law: remove the unobtainable and discriminatory provision that requires licensed midwives to work under the supervision of a physician.

As you are likely aware, physicians are unable to supervise midwives due to restrictions placed on them by their malpractice insurance carriers.  Thus, virtually all licensed midwives in the state of California are practicing illegally, and are in constant and unrelenting danger of prosecution for breaking the law.  They are also prohibited from serving Medi-Cal families because Medi-Cal does not recognize them as independent providers.

Your Efforts Made A Difference: Physician Supervision Removed
However, after several months of advocacy, activism, and rallying, your voices have made a difference, and AB1308 has gone from restating and mandating implementation of physician supervision, to removing it from law altogether.  This is no small feat.

Stay Tuned: We’re Watching For Last Minute Shenanigans
Assemblywoman Bonilla’s office confirmed yesterday that AB1308 will be amended on the Senate floor next week, and removal of physician supervision is one of the amendments.CFAM is taking a strong position in support of this bill, and  Assemblywoman is well aware that our support is contingent on this key amendment.  We will be watching the bill closely to ensure that there are no unanticipated last-minute changes, and we need you to be ready to pull your support if there are any shenanigans.  It’s critical, however, that we all begin contacting legislators right away and letting them know that we support AB1308 with Assemblywoman Bonilla’s proposed amendments.

AB1308 Wins: Increased Access Through Birth Centers and Medi-Cal
The fundamental benefits of passing AB1308 are that it will make licensed midwives legal in California for the first time in two decades, and will authorize state licensure for freestanding birth centers run by licensed midwives.

This means that our midwives will be able to continue providing care for families without fear of losing their licensure and/or being prosecuted, and Medi-Cal will have no choice but to cover out-of-hospital maternity care (both at home and in freestanding birth centers) for the 48% of California moms whose income qualifies them for Medi-Cal.

That is a huge win given the tremendous benefits of midwifery care, and the importance of making this care available to all families regardless of income level.

New Limits On Home Birth Require Our Undivided Attention
Make no mistake, however; this bill is far from perfect.

ACOG has taken full advantage of the fact that the physician supervision requirement leaves midwives vulnerable, and that we need to get a bill passed this year much more than they do.  They know that the midwife-friendly director of the medical board was fired earlier this year.  They know that separate legislation is working its way through the legislature that will shift enforcement of physician supervision to either the Department of Justice or the Division of Investigation.

And their well-funded lobbyists have successfully negotiated for a new provision that narrows midwives’ scope of practice to “normal pregnancy and normal birth,” which they define as:

• Absence of any preexisting maternal disease or condition that is likely to affect the pregnancy
• Absence of significant disease arising from the pregnancy
• Singleton fetus
• Cephalic presentation
• Gestational age between 37 and 42 weeks
• Labor is spontaneous or induced in an outpatient setting

Notably, this definition of normal pregnancy and birth excludes mothers carrying more than one baby and mothers whose babies are in a breech position at birth.  This is not something we take lightly.  Also, for women with “preexisting maternal disease[s] or condition[s],” and women who experience “significant disease” during pregnancy, midwives will be required to refer them to an obstetrician for a determination that their condition is not likely to affect their current pregnancy.

This provision is likely to impact moms having a vaginal birth after a prior cesarean, but we were successful in including language that leaves this door open.  The bill will direct the medical board to craft regulations defining what constitutes a “preexisting maternal disease that is likely to affect the pregnancy,” and that will be the next battleground for preserving access to midwife-supported VBACs.

Our Work Is Not Done Until We Secure A Woman’s Right To Make Her Own Health Care Decisions
Ultimately, however, we cannot create a maternity care system that is responsive to and respectful of the needs of mothers and babies, without addressing the fundamental problem: California has yet to recognize that pregnant women have the same rights as everyone else to make their own decisions regarding their health care.

All of us at CFAM believe that a woman’s human right to self-determination in making health care decisions is basic and self-evident, and is not mitigated by “risk” factors.  No one—not the government, not our doctors, not even our midwives—has the right to force us into a particular course of action, or to prevent us from accessing the maternity care that we decide is best for ourselves and our babies.

We hope that you will join us as we continue to move forward with this movement of mothers and families.  From where we stand, passing AB1308 is a big step forward.  By removing the threat of physician supervision, we can focus the next leg of this journey on the underlying issue: human rights in pregnancy and childbirth.

Here is what you can do now to support this effort:

• Contact your state senator and assemblymember, and urge them to support AB1308 with Bonilla’s amendments only.  Ask your family and friends to do the same
• While you’re at it, tell them how you feel about women’s human rights in childbirth, and let them know it’s an issue that needs to be addressed urgently
• Help us build our numbers. Spread the word while earning a chance to win some #freeourmidwives swag. Learn more here.
• Visit our website and make a donation to CFAM so we don’t have to drag our unpaid bills from this campaign into the next one.

As you can see, our work is not done.  We’re counting on you to move this movement forward because we now know—from experience—that our voices really do make a difference.

All the best,

Adeola Adeseun
Treesa Mclean
Jennifer Heystek
Tanya Smith-Johnson
Louis Heystek

P.S. Please consider a donation TODAY – it will make a huge difference in our work.

Our mailing address is:

What Ca LMs needs to know b4 reading:

First, this is the SAME language as before.

The changes expected to remove physician supervision as a prerequisite of practice can’t be made when the bill goes back to the Assembly for (yet) another hearing.

Second, this Senate analysis provides a number of interesting things, including “the facts” of physician supervision — that it isn’t available, and that EVERYBODY who is anybody, including the Legislature of California,  knows that it doesn’t work.

This is an officially-published public document that could be used in a court of law to established these same “facts” in relation to the current and fatally-flawed provision in the LMPA for physician supervision.

Third, the ‘source’ of its information is identified as ACOG. And onterestingly enough, it contains the exact same objectionable characterization that was used by the MBC in its assessment of the ‘supervision issues’ in the 300+ page Sunset Review document.

Last but not least, this Senate analysis give you the names of everyone who voted, and whether they voted for or against the bill.

The is very useful information that can be used in many helpful ways.

So enjoy 🙂

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SENATE RULES COMMITTEE | AB 1308|
Office of Senate Floor Analyses
1020 N Street, Suite 524
(916) 651-1520 Fax: (916) 327-4478
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THIRD READING

Bill No: AB 1308
Author: Bonilla (D)
Amended: 7/9/13 in Senate
Vote: 21

SENATE BUSINESS, PROF. & ECON. DEV. COMMITTEE : 10-0, 7/1/13
AYES: Lieu, Emmerson, Block, Corbett, Galgiani, Hernandez,
Hill, Padilla, Wyland, Yee

SENATE APPROPRIATIONS COMMITTEE : Senate Rule 28.8

ASSEMBLY FLOOR : 72-0, 5/16/13 – See last page for vote
SUBJECT : Midwifery

SOURCE : American Congress of Obstetricians and
Gynecologists, District IX, California
DIGEST : This bill authorizes a licensed midwife to directly
obtain supplies, devices, obtain and administer drugs and
diagnostic tests, order testing and receive reports that are
necessary to his/her practice of midwifery; deletes the
requirement that the Medical Board of California (MBC) adopt
regulations defining the standard of care and level of
supervision required for the practice of midwifery; requires a
midwife to disclose his/her arrangements for the referral of
complications to a physician for consultation; and authorizes a
licensed midwife to be present at a licensed alternative birth
center.

Existing law:

1. Licenses and regulates some 300 licensed midwives under the
Licensed Midwifery Practice Act of 1993, by the MBC.

2. Creates the Midwifery Advisory Council (MAC) which is
required to make recommendations on matters specified by MBC.
3. Defines the practice of midwifery as the furthering or
undertaking by any licensed midwife, under the supervision of
a licensed physician who has current practice or training in
obstetrics, to assist a woman in childbirth so long as
progress meets criteria accepted as normal.

4. Requires the MBC to adopt regulations defining the
appropriate standard of care and level of supervision
required for the practice of midwifery by July 1, 2003.

5. Permits a licensed midwife to attend cases of normal
childbirth and to provide prenatal, intrapartum and
postpartum care, including family-planning, care for the
mother and immediate care for the newborn under the
supervision of a licensed physician and surgeon.

6. Requires a licensed midwife to disclose orally and in
writing: (a) the scope of a midwife’s practice, as
specified; (b) whether the licensed midwife has liability
coverage; (c) the specific arrangements for the transfer of
care during the prenatal period, hospital transfer during the
intrapartum and postpartum periods and access to appropriate
emergency medical services for mother and baby, if necessary;
and (d) the procedure for reporting complaints to the MBC.

7. Requires a licensed alternative birth center, and a licensed
primary care clinic that provides services as an alternative
birth center, to meet specified requirements, including (a)
meeting the standards for certification established by the
National Association of Childbearing Centers, and (b)
requiring the presence of at least two attendants during
birth, one of whom shall be either a physician and surgeon or
a certified nurse-midwife.
This bill:

1. Authorizes a midwife to directly obtain supplies and
devices, obtain and administer drugs and diagnostic tests,
order testing and receive reports that are necessary to
his/her practice of midwifery and consistent with his/her
scope of practice.

2. Deletes the requirement specifying that the MBC adopt
regulations defining the appropriate standard of care and
level of supervision required for the practice of midwifery.

3. Expands the existing oral and written disclosures required
of a licensed midwife to a prospective client to include the
specific arrangements for the referral of complications to a
physician and surgeon for consultation, and specifies that
the licensed midwife shall not be required to identify a
specific physician and surgeon.

4. Authorizes a licensed midwife, in addition to a physician
and surgeon or a certified nurse-midwife, to be present at a
licensed alternative birth center.

5. Makes a correcting change to refer to the American
Association of Birth Centers rather than the National
Association of Childbearing Centers.

6. Makes legislative findings and declarations relating to
midwifery and licensed midwives.

Background

Midwifery program . A licensed midwife is an individual who has
been issued a license to practice midwifery by the MBC. As
provided under the law, the practice of midwifery authorizes the
licensee, under the supervision of a licensed physician in
active practice, to attend cases of normal childbirth in a home,
birthing clinic or hospital environment. Pathways to midwife
licensure include completion of a three-year postsecondary
education program in an accredited school approved by the MBC,
or through a Challenge Mechanism. Prior to licensure, all
midwives must take and pass the North American Registry of
Midwives examination.

SB 1638 (Figueroa, Chapter 536, Statutes of 2006) required the
MBC to create and appoint a Midwifery Advisory Council. The MAC
is made up of licensed midwives (at least half of the MAC must
be licensed midwives), a board member, a physician and a member
of the public (currently an individual who has used a licensed
midwife). The MBC specifies issues for the MAC to
discuss/resolve and the MAC also identifies issues and obtains
approval from the MBC to develop solutions to the various
matters. Some items that have been discussed include physician
supervision, challenge mechanisms, required reporting and
student midwives. SB 1638 also required licensed midwives to
make annual reports to Office of Statewide Health Planning and
Development (OSHPD) on specified information regarding birth
outcomes, and required the reported data to be consolidated by
OSHPD and reported back to the MBC for inclusion in the MBC’s
annual report.

The MBC approves midwifery schools by conducting a comprehensive
assessment to evaluate the school’s educational program
curriculum and the program’s academic and clinical preparation
equivalent. Schools wishing to obtain approval must submit
supporting documentation to verify that they meet the
requirements of Business and Professions Code (BPC) Section
2512.5. Currently, there are 11 approved midwifery schools. A
licensed midwife must complete 36 hours of continuing education
every two years in areas that fall within the scope of the
practice of midwifery as specified by the MBC.

The licensee population in the midwifery program is small and
the number of disciplinary actions filed against licensees is
also proportionally small with a total of five disciplinary
actions being filed over the past three fiscal years. Of the
four disciplinary actions that have been adjudicated, all have
been resolved with either revocation or license surrender.

Physician supervision . BPC Section 2507 authorizes a licensed
midwife, under the supervision of a licensed physician and
surgeon who has current practice or training in obstetrics, to
attend cases of normal childbirth and to provide prenatal,
intrapartum and postpartum care, including family-planning care
for the mother and immediate care for the newborn.

BPC Section 2507(f) requires the MBC, by July 1, 2003, to adopt
regulations defining the appropriate standard of care and level
of supervision required for the practice of midwifery. Due to
the inability to reach consensus on the supervision issue, the
MBC bifurcated this requirement and in 2006 adopted Standards of
Care for Midwifery. Three previous attempts to resolve the
physician supervision issue via legislation and/or regulation
have been unsuccessful due to the widely divergent opinions of
interested parties and their inability to reach consensus.

Although required by law, physician supervision is essentially
unavailable to licensed midwives performing home births, as
California physicians are generally prohibited by their
malpractice insurance companies from providing supervision of
licensed midwives who perform home births.

According to insurance providers, if physicians supervise or
participate in a home birth they will lose their insurance
coverage resulting in loss of hospital privileges. The
physician supervision requirement creates numerous barriers to
care in that, if the licensed midwife needs to transfer a
patient/baby to the hospital, many hospitals will not accept a
patient transfer from a licensed midwife as the primary provider
who does not have a supervising physician. California, along
with Arkansas and Louisiana, are currently the only states that
require physician supervision of licensed midwives. Among
states that regulate midwives, most require some sort of
collaboration between the midwife and a physician.

The MBC, through the MAC, has held many meetings regarding
physician supervision of licensed midwives and has attempted to
create regulations to address this issue. The concepts of
collaboration such as required consultation, referral, transfer
of care and physician liability have been discussed among the
interested parties with little success. There is disagreement
over the appropriate level of physician supervision with
licensed midwives expressing concern with any limits being
placed on their ability to practice independently. The
physician and liability insurance communities have concerns over
the safety of midwife-assisted homebirths. Specifically, they
are concerned with delays and/or the perceived reluctance of
midwives to refer patients when the situation warrants referral
or transfer of care. The MBC has stated that it ultimately
believes that the physician supervision requirement needs to be
addressed through the legislative process.

In the MBC oversight hearing earlier this year, it was
recommended that the MBC should reach a consensus with
stakeholders on this issue and then submit a specific
legislative proposal to the Senate Business, Professions and
Economic Development Committee regarding the appropriate level
of supervision required for the practice of midwifery.

Diagnostic lab accounts . This bill echoes an issue raised by
the MBC in its Sunset Report. Licensed midwives have difficulty
securing diagnostic lab accounts, even though they are legally
allowed to have lab accounts. Many labs require proof of
physician supervision. In addition, licensed midwives are not
able to obtain the medical supplies they have been trained and
are expected to use including: oxygen, necessary medications
and medical supplies that are included in approved licensed
midwifery school curriculum. The inability for a licensed
midwife to order lab tests often means the patient will not
obtain the necessary tests to help the midwife monitor the
patient during pregnancy. In addition, not being able to obtain
the necessary medical supplies for the practice of midwifery
adds additional risk to the licensed midwife’s patient and
child.

The MBC, through the MAC, held meetings regarding the lab order
and medical supplies/medication issues and has attempted to
create regulatory language to address this issue. However,
based upon discussions with interested parties, it appears the
lab order and medical supplies/medication issues will need to be
addressed through the legislative process.

FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes

SUPPORT : (Verified 8/13/13)

American Congress of Obstetricians and Gynecologists, District
IX, California (source)
California Association of Midwives
California Families for Access to Midwives

ARGUMENTS IN SUPPORT : According to the author, “The
California Medical Board is responsible for the oversight of
licensed midwives in California. Licensed midwives deliver
children in a patient’s home or at a birthing center. The
Medical Board is under sunset review this year and has
recommended legislative action on several issues that it has
been unable to resolve in past discussions. AB 1308 seeks to
remove barriers to midwifery while protecting patients. One
such barrier is access to supplies and tests. Currently,
midwives have the authority to obtain supplies in their scope of
practice. Unfortunately, many times they encounter problems in
the field when a supplier or laboratory requires an ordering
physician to be listed. Because midwives do not always have an
ordering physician, it can be difficult for them to obtain
supplies, order tests, or receive reports. Ready access to
these supplies and tests is vital to the safe practice of
midwifery. Another barrier is the ability to work in licensed
alternative birth centers. Licensed midwives are the
out-of-hospital birth experts and it is consistent with this
expertise to authorize them to work in such a setting.”

ASSEMBLY FLOOR : 72-0, 5/16/13

AYES: Achadjian, Alejo, Ammiano, Atkins, Bigelow, Bloom,
Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,
Buchanan, Ian Calderon, Campos, Chau, Chávez, Chesbro, Conway,
Cooley, Dahle, Daly, Dickinson, Donnelly, Eggman, Fong, Fox,
Frazier, Garcia, Gatto, Gomez, Gordon, Gorell, Gray, Hagman,
Hall, Harkey, Roger Hernández, Jones, Jones-Sawyer, Levine,
Linder, Logue, Lowenthal, Maienschein, Mansoor, Medina,
Mitchell, Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan,
Patterson, Perea, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon,
Salas, Skinner, Ting, Torres, Wagner, Waldron, Weber,
Wieckowski, Wilk, Williams, Yamada, John A. Pérez

NO VOTE RECORDED: Allen, Beth Gaines, Grove, Holden, Melendez,
Morrell, Stone, Vacancy

          MW:k  8/13/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

                                   ****  END  ****

Association of Autism With Induced or Augmented Childbirth in North Carolina Birth Record (1990-1998) and Education Research (1997-2007) Databases

The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

May 7, 2013

New Orleans, LA — Induction and augmentation of labor with the hormone oxytocin may not be as safe for full-term newborns as previously believed, according to research presented today at the Annual Clinical Meeting of The American College of Obstetricians and Gynecologists. Researchers say this is the first study of its kind to present data on the adverse effects of Pitocin use on newborns.

Given intravenously, Pitocin (a brand of oxytocin), is often used to start labor when a pregnant woman is overdue. It is also used to keep a lagging labor going by increasing the frequency, duration, and intensity of uterine contractions.

Primary Investigator Michael S. Tsimis, MD, and fellow researchers at Beth Israel Medical Center in New York City, conducted a retrospective analysis of deliveries that were induced or augmented with oxytocin. The study included more than 3,000 women delivering full-term infants from 2009 to 2011. The researchers used the Adverse Outcome Index, one of several tools used to measure unexpected outcomes in the perinatal setting and to track obstetric illness and death rates.

“As a community of practitioners, we know the adverse effects of Pitocin from the maternal side,” Dr. Tsimis said, “but much less so from the neonatal side. These results suggest that Pitocin use is associated with adverse effects on neonatal outcomes. It underscores the importance of using valid medical indications when Pitocin is used.”

Researchers found that induction and augmentation of labor with oxytocin was:

• an independent risk factor for unexpected admission to the NICU lasting more than 24 hours for full-term infants
• Augmentation also correlated with Apgar scores of fewer than seven at five minutes

The Apgar is a test that evaluates a newborn’s physical condition at one and five minutes after birth based on appearance (skin coloration), pulse (heart rate), grimace response (medically known as “reflex irritability”), activity and muscle tone, and respiration (breathing rate and effort). A baby who scores eight and above is generally considered to be in good health.

The analysis suggests that oxytocin use may not be as safe as once thought and that proper indications for its use should be documented for further study.

“However, we don’t want to discourage the use of Pitocin, but simply want a more systematic and conscientious approach to the indications for its use,”Dr. Tsimis said.

*Tuesday Poster #74: Oxytocin Usage for Labor Induction or Augmentation and Adverse Neonatal Outcomes

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women.

As a private, voluntary, nonprofit membership organization of approximately 57,000 members, The College strongly advocates for:

• quality health care for women
• maintains the highest standards of clinical practice
• and continuing education of its members
• promotes patient education
• increases awareness among its members and the public of the changing issues facing women’s health care 

News Flash #1 ~ Tosi Marceline is newest LM member of the Midwifery Advisory Council

News Flash #2 ~ Constance Rock and Sara Davis gave their report on the most updated version of AB 1308 during today’s Midwifery Council meeting (webcast available on line!)

They had extraordiary news, but remember that AB 1308 is still a bill, not a law. Until it is has officially passed by the Legislature, and signed into law by the Governor, things could still change.

So be real happy, but don’t go too crazy — at least, not yet.

Here is the wonderful news….. Drum roll PLEASE! 

For the first time ACOG agreed to “striking supervision from the LMPA”.

However, it requires that the scope of practice for California LM be restricted to “normal birth”.

This is defined as single fetus in a vertex position between 37 and 42 wks of pregnancy. If a mfry client is determined to have a preexisting condition (including previous C-section) the mother must be evaluated by an obstetrician before returning to LM care.

The current arrangement allows concurrent prenatal care by LMs for childbearing women who have risked out for PHB. It also recognizes emergent care by an LM for a precipitous labor/birth of twins or breeches or other risked-out categories.

And yes, this creates a new set of problems that will have to be fixed at a later date.

Another provision in this amendment is language that limits the liability of physicians after transfer from licensed midwifery.

Last but not least are instructions to the MBC to align the current LMAR criteria with those used by MANA and to encourage all midwives to file their stats on the LMAR and MANA both.

Watch the webcast for more details and to see the discussion. I don’t have the link right now, but i should be available in the next 24 hours.

As for the obvious issues — the lost of autonomy for childbearing women — yes, this is a real problem, one that will require a real legislative solution.

But first, we must go forward with the repeal of supervision. Then mothers and midwives and other consumer and constitutional advocates will have to get additional legislation passed that makes the brings our law back into alignment with the rights of a healthy adults to make their own health care decisions .

A healthy woman’s right to determine the manner and circumstance of her normal labor and birth is just that — a human right. Its not up to obstetricians or midwives to demand that healthy women with normal pregnancies have a highly medicalized hospital birth over their objection and fully informed decline.

Another missing piece is hospital privileges for licensed midwives, so that a mother-to-be who risks out for PHB or who simply decides she doesn’t want to give birth in an OOH setting can still have a physiologically-managed labor and birth.

So stay tune — things are just getting interesting!

Twilight Sleep drugs, general anesthesia and routine use of episiotomy, forceps and manual removal of the placenta were first introduced in the early 1900s, when the perspective of the obstetrical profession was that childbirth itself was a pathological aspect of biology. This generated policies that naturally and consistently ratcheted up the medicalization of labor and birth in healthy women.

Unfortunately, these laboring women narcotized, given repeated doses of hallucinogenic and amnesic drugs and ultimately rendered unconscious with general anesthesia. Adding insult to this institutionalized injury, when these medicated women reported their distressing experiences, their accounts were deemed unreliable based on the effect of the drugs.

However, letters by whistle-blowing L&D nurses published in Laddies Home Journal in the 1950s confirmed their accounts and in addition described the routine abuse of laboring women by physicians and L&D staff that we now would consider criminal. But the occasional and unorganized social pressure of the small number of dissidents was politically inadequate and made only the tiniest dent in the armor of obstetrics, mainly in a few upscale New York City hospitals who offered classes in ‘natural childbirth’ and allowed a few select women to remain unanesthetized during their medicalized ‘delivery’.

In large and small hospitals across the rest of the country, obstetrics continued to be an practiced as if it were a private all-male club that make up its own rules and did as it saw fit, and believing that only obstetricians could possibly know what was best for childbearing women. Obstetrics was in essence practiced as veterinary medicine, in that it treated laboring women as pets with no say in the treatments the were forced to endure.

However, the renissaance of midwifery due to Ina May and Steven Gaskins, as well as other remarkable pioneer women such as   exchanged the 60-plus years of   for “awake and aware” childbirth. This was the beginning of curtains, rugs, blond wooden cabinets secreting medical paraphernalia, and finally husbands and eventually other family members including children at labors and births

Home birth midwives can and should the take credit for triggering the biggest positive change in American obstetrical practices. The last big  since the adoption of scopolamine (Twilight Sleep) as the standard of care in 1912. Unfortunately the job of transforming childbirth practices will not be done until healthy women with normal pregnancies can reliably receive physiological management as the universal standard of care from all types of birth attendants (obstetricians, FP docs and midwives) and in all setting (home, hospital and birth centers).

However, women as midwives and mothers have been caught in a Mexican stand-off for the last 30 years. Obstetricians and medicalized management in hospitals was and continues to be pitted against midwives and physiologic care in OOH setting. Its pretty obvious that the stance of obstetrics is ‘never the twain shall meet’/ hell-no-we-wont-cooperate and you can’t make us.

For the last 100 years the maternity department had been the cash cow of the hospital business. Hospital depend on revenue generated by the elective hospitalization of heathy maternity patients to keep the lights on, depend on the recommendations of maternity patients as ‘satisfied customers to keep their beds full.

Doctors are not ever going to sign up for lessons in how to provided non-medical management. The only way to change with thinking and eventually reform medical educate and obstetrical practice is for other things to change so dramatically that they decide its a good idea for them to make these changes.

In order to reform the way obstetricians managed normal childbirth, midwives are going to have to make physiologic childbirth in birth centers into the new “hot” thing by creating a middle ground — birth centers — that does not seem ‘scary’ and has a lot of to recommend it. I like Constance’s description of a birth centers as a wonder opportunity for women to labor and give birth in a mother-baby-family friendly “Bed and Breakfast”. The fact these qualify for Medicaid-MediCal reimbursement means that the 85% of healthy women with normal pregnancies actually have access, for the first time in a hundred years, to reliable and cost-effective physiologic childbirth services.