Midwives hope for autonomy from state bill

David Briggs
Joan Green, a seasoned midwife who lives in Lagunitas, listens to a heartbeat. She may be largely unaffected by a midwifery bill now before the state senate, but advocacy groups are hoping to soon free licensed midwives from a mandate to practice under a physician.
07/03/2013

Legislation passed by the state assembly in May and by a senate committee on Monday would ease some restrictions faced by midwives in California but would not lift a requirement of physician oversight. That law, though currently unenforced, effectively bars Medi-Cal recipients—25 to 30 percent of Marin’s pregnant women—from midwifery services.

Pushing to allow licensed midwives to operate independently and lawfully are both midwives themselves and a coalition representing families. They say home birth offers a holistic model of pregnancy that empowers women during the nine-month journey to motherhood as well as during birth. 

Assembly Bill 1308 would ensure that licensed midwives have access to medical supplies, lab tests and other necessities to serve women seeking to give birth in their homes; it would also allow midwives to practice in state-licensed home birthing centers.

California charged physicians with oversight of midwives practicing home births in 1993, when midwifery became legal in the state. But, due to medical malpractice insurers’ liability concerns, almost no midwives in California can procure physician supervision.

“[The supervisory requirement] has never been enforced because it’s never been attainable,” said Joan Green, a Lagunitas resident and midwife who has practiced for 29 years. It has also posed problems for midwives in other areas of the state wishing to access equipment from medical supply stores.

If the hierarchical stipulation were scrapped or otherwise fixed, it would not only allow midwives to follow the letter of the law but also open up their services to women on Medi-Cal, the state program that provides insurance to low-income populations and has more lenient income thresholds during pregnancy. 

Unofficial 2012 data provided by Marin County found that there were 56 births not assigned to a hospital out of a total 2,300 births, or 2.4 percent. Most of those were likely home births, though some could have taken place en route to a hospital, according to Sandra Rosenblum, the maternal child and adolescent health director for the county. 

In the United States at large, home births are on the rise, though they are still uncommon. From 2004 to 2009, home births increased by 29 percent, moving from 0.56 percent to 0.72 percent of all births, according to the Centers for Disease Control. 

Aveola Adeseun, who leads the advocacy group California Families for Access to Midwives, felt that midwives scored a small victory on Monday when legislators struck from the bill a timeline for the state medical board to create regulations around physician supervision. 

But Ms. Adeseun added that the debate over supervision itself is a bigger battle. “It was like the appetizer, and it’s about to be dinner-time,” she said.

Ms. Adeseun cited a recent statement by a representative of the American College of Obstetricians and Gynecologists that home births in optimal circumstances can be safe as a reason for her optimism that the oversight requirement will be eliminated at some point. 

A lobbyist for the American College of Obstetricians and Gynecologists, Shannon Smith-Crowley, said that her group believes there needs to be a requirement for an official relationship so that when situations in which disciplinary action is needed there is a law on the books to refer to. 

“When everything’s good, it’s great, but when there’s a problem, we need to know how to deal with it,” she said, adding that the law should be broad to allow the medical board to tackle the specifics. 

“It is best for everybody concerned, for healthy moms and babies, to have a better-integrated working relationship,” she said. 

American College of Obstetricians and Gynecologists supports A.B. 1308 because of the current problems midwives have accessing equipment. Ms. Smith-Crowley said that data do show that home births can be as safe as hospitals in ideal situations, although the organization still holds that hospitals are safer in general.

As far as the practical problems with physician regulation, Ms. Smith-Crowley said that challenge needs to be addressed but that, for instance, her organization is working with the University of California to explore whether its hospital system, which is self-insured, might consider working with midwives. 

Advocacy groups like California Families for Access to Midwives believe that another piece of legislation, S.B. 304, which would shift enforcement of regulations from the Medical Board of California to the California Department of Justice, could bring an attempt to enforce the physician requirement. 

Sarah Davis, the vice president of the California Midwives Association, said it was a possibility, but added, “It’s a question mark.”

A.B. 1308 would also authorize midwives to operate not only in homes but in state-licensed home birthing centers. “That brings California closer in line with Affordable Care Act, because the A.C.A. is very supportive of state-licensed birth centers,” Ms. Davis said.

A clinical opinion published in January in the American Journal of Obstetrics and Oncology, which provided an overview of some of the objections that physicians have to home birth, claimed that “the best screening procedures, even when optimally performed, sometimes fail to detect these high risk conditions” and that dangerous situations can escalate quickly. 

One meta-analysis, published in the same journal in 2010, found that home births resulted in fewer medical interventions and a reduced incidence of premature labor in women but were three times as likely to result in neonatal death—deaths between seven and 28 days of life—although the latter was hotly disputed by home birth advocates who raised questions about its methodology.

Ms. Davis pushed back against the argument that home births can be dangerous because medical emergencies can arise quickly and without warning. “To the point that things can shift very quickly, it’s important to remember that in out-of-hospital births, we don’t use any pain medication or anesthesia. We don’t use any medication to speed up labor.” 

Midwives, who in California must complete a three-year program at one of 11 board-approved midwifery schools in the country to obtain a license, also only serve women with normal, low-risk pregnancies, a point Ms. Green reiterated.

“A lot of women choose midwifery and home birth in particular… because they feel pregnancy is not an illness and they feel that by choosing to have their baby at home, they have more control over the situation. They feel it can be more honored,” she said.

Medical issues can still arise, however. After Inverness Park resident Salihah Kirby gave birth to her daughter about eight months ago, she started hemorrhaging. But her midwife, who had a second midwife on hand during her patient’s labor, was able to handle the situation. 

Ms. Kirby has not had second thoughts about her choice. 

“I felt so safe, I felt completely taken care of. There was not one little bit of fear or doubt in my mind,” she said. “It was the best experience of my life, for sure.”

Though Ms. Kirby didn’t need to be transported to a hospital, one of the potential risks West Marin women face is a long travel time. Ms. Green, who cares for about 20 to 25 women a year, said none of her clients have ever needed emergency transport. 

Ms. Adeseun added that while there are risks unique to home births, there are also risks in hospitals that don’t arise during home births. “It is up to mother to decide which risks they are comfortable with,” she said.