Physicians group out of step as Health Care Organizations supporting CPMs increases

WASHINGTON, D.C. (February 17, 2009)—Two major health care organizations have joined the growing number of groups calling on policy makers to increase access to Certified Professional Midwives (CPMs) and out-of-hospital maternity care. Acknowledging the large body of evidence supporting the safety of home delivery with CPMs, who are specifically trained to care for mothers and babies in out-of-hospital settings, nursing and perinatal health care organizations criticized the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) resolutions calling for bans on CPMs and home birth. The groups also joined Consumer Reports magazine in highlighting the need for a major overhaul of the U.S. maternity care system. “I am very proud to be an American, but I am embarrassed that our country, founded on the ideals of individual liberty and freedom, can also support ‘authoritative’ initiatives such as these by the ACOG and AMA, initiatives that are founded on neither science nor an understanding of the physiologic and psychosocial needs of mothers and babies,” said Nancy K. Lowe in an editorial published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, the official journal of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). “What is most risky about home birth in the United States is that for most women who desire it there is a scarcity of qualified providers of home birth services.” Consumer Reports magazine cited the desire for economic gain as one of the driving forces limiting access to CPMs and Certified Nurse-Midwives (CNMs), who are licensed in all 50 states and practice primarily in hospital settings, but who remain subject to anti-competitive regulations promoted by the AMA and ACOG. CPMs are legally authorized to provide out-of-hospital care in just half the states, while advocates working to reform the law in the remaining states face stiff resistance from physician groups seeking to establish a monopoly on the maternity care market in the U.S. “Midwives provide a safe and cost-effective alternative to the current model, where the market is dominated by high-cost, high-tech specialists producing less-than-optimal outcomes,” said Katie Prown of The Big Push for Midwives Campaign. “Babies delivered by midwives are far less likely to be pre-term or low birth-weight, which are two of the leading causes of neonatal mortality and of the enormous costs associated with long-term care. Midwives and out-of-hospital birth are an integral component of responsible health care reform, and the AMA and ACOG know this. That’s why they’re fighting so desperately to protect their turf, even if it means denying women maternity-care options in the process.” The National Perinatal Association (NPA) added to the growing list of organizations calling on the AMA and ACOG to end their vendetta against midwives and home birth and instead follow the World Health Organization’s (WHO) call to “‘work in a spirit of recognition and respect for each other’s authority, responsibility, ability and unique contribution.’” The Big Push for Midwives is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico, and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care. Through its work with state-level advocates, the Big Push is helping to build a new model of U.S. maternity care built on expanding access to out-of-hospital maternity care and CPMs, who provide affordable, quality, community-based care that is proven to reduce costly and preventable interventions as well as the rate of low birth-weight and premature births. Media inquiries: Steff Hedenkamp (816) 506-4630, steff@thebigpushformidwives.org.

Home-birth advocates press pro-midwife campaign

By DAVID CRARY

NEW YORK (AP) — With health care costs high on the national agenda, advocates of home births are challenging the medical and political establishments to give midwives a larger role in maternity care and to ease the state laws that limit their out-of-hospital practice.

Pending bills to further this goal have significant backing in several states, which home-birth supporters want to add to the 25 states that already have taken such steps.

Nationally, a group called the Big Push for Midwives marked President Barack Obama’s inauguration with an e-mail campaign urging him to ensure that midwives who specialize in home births are included in deliberations on federal health care reform.

“We’re at a tipping point now,” said Katherine Prown, the Big Push campaign manager. “Home births are still only a small part of the total, but it’s poised for growth.”

The campaign seeks to emphasize that in this time of economic crisis, home births can be a safe, satisfying and moneysaving option for many women. But it runs into adamant opposition from the American Medical Association and the American College of Obstetricians and Gynecologists.

“Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause celebre,” the obstetricians’ policy statement says. “Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.”

According to the latest federal data, there were only about 25,000 home births nationally in 2006 — most of them assisted by midwives — out of nearly 4.3 million total births.

Midwife-attended home births increased by 27 percent between 1996 and 2006. Home-birth advocates believe the numbers will rise as more states amend their laws to accommodate the practice, which they contend is at least as safe as hospital births for healthy women with low-risk pregnancies.

One of the strengths of the state-by-state campaign is its diversity, Prown said.

“We’re one of the few movements that’s succeeded in bringing together pro-life and pro-choice activists, liberal feminists and Christian conservatives,” she said. “In every state we manage to recruit Republican and Democratic co-sponsors who normally would never be on the same bill together.”

The states are now evenly split on legal recognition of certified professional midwives (CPMs) — those who lack nursing degrees and who account for most midwife-assisted home births.

Half the states have procedures allowing CPMs to practice legally — including five which have taken such steps since 2005. The other 25 states lack such procedures and CPMs are subject to prosecution for practicing medicine without a license.

Depending on legislative decisions, the balance could shift this year. Among the battlegrounds:

_In North Carolina, a House study committee recommended in December that the legislature develop licensing standards for CPMs. The committee said the current system doesn’t meet the needs of women who chose non-hospital births because of the “extremely limited supply” of obstetricians and nurse-midwives offering to handle such births.

_In Idaho, advocates who failed previously to get a voluntary licensing bill through the legislature are back with a mandatory licensing bill. State Rep. Janice McGeachin, R-Idaho Falls, says the changes helped persuade the state boards of nursing and pharmacy to drop their opposition. The Idaho Medical Association, which fought the earlier version, has expressed respect for the changes in the bill and is deliberating on whether further changes might produce a version it could accept.

_In Illinois, advocates also are back with a new version of a licensing bill that failed in 2007. Rep. Julie Hamos, D-Evanston, says it toughens qualification standards for CPMs — changes that prompted the Illinois Nurses Association to drop its opposition. The Illinois State Medical Society remains opposed.

“There are many in the legislature who feel a need to have this option — they need to be educated,” said Dr. Shastri Swaminathan, the society’s president. “We’re in strong opposition to licensing midwives who don’t have the medical training to provide safe home births.”

Cost is a major element in the debate. A routine hospital birth often can cost $8,000 to $10,000, with higher bills for cesarean section deliveries that now account for 31 percent of U.S. births.

Midwives’ fees for home births are often less than a third of the hospital cost, in part because the mothers generally don’t receive epidural anesthesia or various other medical interventions at home.

For pregnant women, insurance coverage can be a decisive factor in their choice. Many insurers cover care by nurse-midwives in hospitals; coverage is less common for midwives who aren’t nurses or who assist with home births.

Many obstetricians acknowledge that the spiraling cost of maternity care and high rate of C-sections are problems.

“But the answer is not to have births at home,” said Dr. Erin Tracy, an obstetrician at Massachusetts General Hospital in Boston. “We obviously support women’s empowerment, but the No. 1 guiding principle has to be the health and safety of the mother and baby.”

The national physicians’ groups do support births assisted in hospitals and birthing centers by midwives who’ve completed nursing school or an equivalent postgraduate program.

The American College of Nurse-Midwives, which represents these midwives, says it differs from the AMA in considering home births a legitimate option for pregnant women. But the college says only nurse-midwives or others with comparable training should be allowed to assist.

“We don’t believe it’s safe without being integrated into the full health care system,” said Melissa Avery, the college’s president.

The education standards endorsed by the college would exclude many of the estimated 1,400 certified professional midwives, who often acquire training through apprenticeships.

Jane Peterson of Iola, Wis., is an example. She began a midwife apprenticeship in 1980 and has attended more than 1,330 births since then, many of them before she and her counterparts were legally authorized to practice under a 2005 state law.

Peterson, 56, said she strives to develop collaborative relations with local doctors so that transfers to hospitals go smoothly if risk factors develop. She believes such cooperation should be encouraged nationwide, so more women can feel comfortable about choosing home births.

“People will tell you that you changed their lives,” said Peterson, reflecting on the rewards of her job.

“It’s hard work — getting up on a cold winter night, going out one more time through the snow. What keeps you going is the recognition women feel — as though they are a different kind of mother when they’ve been able to give birth their way.”