The case for focusing on affordable maternity care instead of supervision

Making Legislation about Mothers and Affordable Maternity Care,
and not about midwives, and the doctors who refuse to provide supervision

I think we are served by not focusing tightly on us, as midwives or about midwifery per se — that is, I think there is considerable advantage to not using the word “midwife” or “midwifery” as the identified focus of our legislative efforts

For the public, midwifery is as a word generally invokes mental images of Scarlett O’Hara’s maid saying that she didn’t know “nothing about birth’n no babies”, as Atlanta burned in the background. For the medical profession, midwifery is about who ‘delivers’ the baby, and therefore triggers the century-long food-fight over which profession is most qualified to ‘control’ the second stage of labor.

Maternity care is far more, but never less, than attending births

However what midwives actually do is SO MUCH MORE than the few minutes we function as legally-responsible birth attendants. Only about 5% of the total time (typically about 25 hours) we spend providing care to childbearing families is about ‘catching the baby’ — that is, managing the last few minutes of the perineal stage and the baby’s first breath, which is the medical definition of the surgical procedure of a ‘delivery’, which is the only part that obstetricians play in the course of labor, birth and postpartum-neonatal care.

By making access to affordable MATERNITY care by California families our issue of concern, we refocus the discussion on the whole spectrum of maternity care as a vitally important aspect of HEALTH care — access to maternal-infant health education, nutrition and dietary counseling, breastfeeding advise, child development issues, family planning information, avoiding intergenerational hypertension, type II diabetes and obesity, etc.

This includes pre and post-natal appointments that are a minimum of 30 minutes in length and scheduled house calls before, during and after the birth (irrespective of the designated place-of-birth). The goal is high-quality, high-value individualized health care at this key time in the life of women and unborn/newborn babies

These maternity services are something that even people who don’t have kids and/or aren’t ever planning to get pregnant can understand. As for the number$, every state employee and member of the Legislature knows that money saved by preventing the need for medical services is money available for pre-K education, community college system, infrastructure maintenance, anti-terroism security, whatever.

By labeling ‘supervision’ as a policy that prevents the provision of affordable maternity care in California by professionally-regulated midwives, we have a very significant advantage over other, earlier efforts to ‘repeal’ supervision. These turned out to be fights between doctors and midwives over who was going to control the actions of midwives based on spurious claims of ‘safety’, whether midwives carried liability insurance and whether med-mal carriers would “let” doctors consult or collaborate with LMs.

These earlier legislative efforts were about what doctors did and didn’t want. Unfortunately organized medicine used this focus on doctors and midwives and medical malpractice issues to obscure or distract us all from the most crucial piece of the story – affordable care for mothers and babies. Its useful to note that supervision as constructed by ACOG does not apply to care of the neonate, which is a totally different discipline. Obviously obstetricians and organized medicine did not lobby for mandatory supervision by perinatologist or pediatrician. I guess its safe to assume that they are not concerned about the economic fortunes of the pediatric profession or the ‘safety’ of neonates.

So far the licensed mfry profession has missed the boat 3 times when we attempted to repeal supervision – first with Assemblywoman Strom-Martin in 1999 and the two under Figureoa. The way these legislative attempts were structured made them primarily seen as merely amendments to the LMPA, which made it look like its purpose was to better the working conditions of midwives.

Unfortunately, this made efforts to fix ‘our’ problem of supervision into a turf war against a well-financed and tactically superior group that turned it into a showdown at High Noon. At the appointed time, we midwives showed up at their gun fight with a pee-shooter and chanted “please be nice to midwives, cause we’re so nice to you, if you’ll be nice to midwives, we’ll be nice to you”.

The real issue relative to mandated-but-systematically-unobtainable obstetrical supervision was that it blocked access to the full spectrum of affordable maternity care by essentially healthy women.   But that wasn’t what midwives were saying — we kept talking about how we couldn’t find a physician who was willing to supervise us. That made the public conversation about midwives, and how hard we ‘tried’, the relative safety of OOH birth and whether or not we had our own med-mal coverage.

Supervision created and maintained a monopoly by the obstetrical profession over all maternity care revenue streams, but we didn’t say that either. Like a good battered wife, we didn’t want to piss ’em off by telling a bold-faced Truth in public. After all, we depended on the good will of a tiny sliver of OBs to be nice to us or our moms.

Then AMA-CMA and the obstetrical professional manipulated the state-federal reimbursement system for the 40% of low-income women, so it cut licensed midwives out of the picture and the ONLY care available to Medicaid/Medical pregnant women was the most costly, most highly interventive type of hospital-based obstetrics.

But we didn’t notice, or didn’t care, or didn’t think it was ‘wise’ to discuss ‘welfare’ issues in public. From the perspective of public health policy and balancing the state budget, this was the big ticket item — the most compelling reason for fixing the problem.

I don’t know why we didn’t talk about it, but the answer doesn’t much matter anymore. Collectively it was a serious tactical error.

For the purposes of public conversations and the Sunset Review materials, I urge midwives to think, and talk about our efforts as devoted to the: “The California Affordable Maternity Care Act of 2013“. The use of mandatory supervision by the obstetrical profession as a way to control the midwifery profession was never in the public interest and its demise will become a natural consequence for affordable maternity care.