Open Letter to Ca LMs on AB 1308 & historical issues of mfry in California

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:

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:

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.

Marla Hicks, RN-BC, CPM, LM

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