2015 Join the Campaign to Remove Supervision
All Midwives Care About Reducing Cesareans AND
Increasing Options for Vaginal Births After Cesareans.
2015 Join the Campaign to Remove Supervision (written one year ago)
We are delighted to announce that a transformative new midwifery bill (AB1306) has been introduced in the California State Assembly. It stands to fully authorize nurse midwifery care both within and outside the hospital setting. The intent of the bill is to remove restrictive language from previous laws so as to allow for improved collaborative care provided by nurse midwives and their physician colleagues. Its arrival is the result of significant good faith integration of research between nurse midwife and obstetric organizations; this represents a targeted effort to establish the safest possible middle ground between countervailing positions regarding best birth practices. The reasons for this bill’s timeliness are as illuminative as the political truces it has inspired. Both show an awareness of the maturing of public opinion on the subject of birth: reducing risk in childbirth requires clear pathways for seamless collaboration between “different but integrated” models of care.
97% of Certified Nurse Midwife (CNM) care in California is provided in hospital settings in close collaboration with physicians. In these settings, nurse-midwives often face arbitrary requirements to demonstrate a supervisory relationship with a physician. This results in limiting the ability of CNMs to provide care in a variety of geographic areas and healthcare facilities, as well as limiting their ability to provide full scope of services in underserved communities. Providing supervision to fully qualified CNMs places an outdated and unnecessary burden on physicians. Most facilities require physician co-signatures for admission and discharge, even though the physician may not have been present during care and may not have had a personal encounter with the patient. This results in physicians providing record-keeping documentation when they could be providing direct care to patients.
The Risks of Hospital vs. Home Birth Deliveries
The difficulty in obtaining a supervisor has resulted in barriers to provision of care to women seeking out-of-hospital services. Though out of hospital births account for only 3% of CNM led care, conversations around home and birth center birth get the lion’s share of attention. In it’s February 24 Room For Debate series “How Safe is Home Birth”, the New York Times has helped focus attention on key points of concern. While posited as a debate, there is little disagreement about the findings for both midwives and doctors.
- The rise in C-sections in the U.S. has not been associated with improved outcomes for mothers or babies, suggesting that many are unnecessary. Home births are on the rise as more women seek empowered options in navigating the hospital setting and/or limiting their need for hospital interventions. They require trained guides to help evaluate medical risks.
- Low risk births should be afforded a full spectrum of home birth options including certified professional midwives and certified nurse midwives working collaboratively with physicians.
- The hospital is the safest option for high-risk births. Well educated certified nurse midwives are specifically equipped to assess for conditions of risk as they arise in home birth. They play a critical role in deciding when to transport to higher levels of maternity care.
- When complications arise, the triage from home birth to hospital must be improved to decrease neonatal morbidity rates.
- The ability of a care provider to rapidly respond with emergency services, as needed, is a life and death matter for mother and baby. The law must support the ability of midwives to access lifesaving medications, thus providing this emergency care in the home setting or while awaiting transport to a hospital facility.
In sum, there is a need to improve the quality of care and communication in the following areas of overlap between home and hospital: collaborative perinatal risk assessments between midwives and physicians; seamless transfers to hospitals should emergencies arise; and rapid access to emergency measures as required. Such steps will directly reduce all the risk factors outlined by the combined studies of midwifery and physician organizations. But first, the laws regarding physician supervision must be modernized to remove risks of liability faced by doctors.
The Liability Hazards of Home Birth Deliveries in California
Whether or not you would choose to have a home birth, most California citizen’s are under the impression that there are legal mechanisms in place to have a midwife in attendance at home, preferably a midwife with medical training. As it turns out, medical malpractice insurance companies are not beholden to your right to a home birth and have excluded coverage to any physician that associates with home birth midwives in a supervisory capacity. As such, midwives and physicians who are willing and able to provide collaborative care in the home are bound by liability to remain at arms length from one another.
For the past forty years, midwives in California and the Board of Registered Nursing (BRN) that oversee them have interpreted the intent of the “under the supervision of a physician” clause to mean “in collaboration and consultation with a team of physicians” (as it is practiced nationally). This omits the obstacle of forcing the supervising signature of any one physician while following the intent of the law. This also ensures that there are many OBGYNs, hospitalists, and doctors who are ready for consultation and for emergency transfers should they be needed
Though this collaborative style of physician / midwife interaction has been working increasingly well over the last 10 years, physicians know the insurance risks at stake and are thus still obligated to distance themselves from any overlap of care between the hospital and home settings. This liability conundrum faced by physicians creates unnecessary risks for all players; consumers, midwives, and doctors alike. Malpractice coverage is available and carried by most CNMs.
The Solution – Key Provisions of AB 1306
Increased autonomy in practice brings increased measures for self regulation and accountability. Midwifery offers an emphasis on birth as a natural, physiologic process, allowing for a full suite of services (in keeping with the unique values and health perspectives of families) that are not necessarily addressed within the medical model of care. Though this physiologic model of care is different than the medical model, they are aligned within standards of care described in the ACOG/ACNM joint statement.
- All newly licensed CNMs will have national AMCB certification, in line with national standards.
Regarding medical malpractice insurance, physicians and midwives need to be held legally liable (and protected) only according to the standards of care of their own “different but integrated” professions. CNMs can obtain malpractice insurance with or without physician supervision. Were physician supervision removed from state statute, CNMs would continue to be able to obtain independent malpractice coverage.
- Nurse-midwives will continue to practice in collaboration with physicians, but without the barriers imposed by supervisory language.
AB 1306 will define the mechanisms that bridge physiologic and medical models of care while recognizing that they remain distinct. As advances in both models of care take place over time, so too will the definition of “low risk births”. The lack of specificity regarding how to define low risk births as applied to midwifery creates an untenable situation for the BRN charged with legal oversight of CNM practices. In order to make clear the standards of safety within this evolving landscape, the BRN review committee has insisted that a CNM advisory group be charged with making updated bulletins with specific interpretations of law. This bill makes such a group mandatory.
- The BRN will receive support on regulatory issues impacting CNMs via a nurse-midwifery advisory council.
Though the provision and implementation of emergency procedures has always been within the scope of practice for certified nurse midwives, the bill specifies that midwives can perform all functions within their scope of practice under their own authority rather than under standardized procedures. The bill also allows for these procedures to be allowed in all settings including the home. Episiotomy, laceration repair, and the furnishing of pharmaceutical medications are included as instrumental provisions of emergency care in the home setting or while awaiting transport to a hospital facility
- Home birth and birth center CNMs will have access to medications and resources necessary for safe care.