Mo. midwives say state laws too restrictive

Efforts to ease state regulations failed in the General Assembly.
Monday, June 13, 2005 | 12:00 a.m. CDT; updated 11:13 a.m. CDT, Monday, July 21, 2008

After delivering thousands of babies over the past 30 years, Diane Barnes, a certified nurse-midwife, is ready to finish up her practice and retire.

“I’ve delivered thousands of babies in Missouri, and I would like to retire with respect,” said Barnes, the former president of the Midwives Alliance of North America.

Barnes’ fate as a midwife hinges on a ruling by the State Board of Nursing, after she violated the Nursing Practice Act for not having an obstetrician/gynecologist on call as a backup. The discipline she faces could range from censure to revocation of her license.

Christine Skinner, president of Friends of Missouri Midwives, said Missouri has some of the most restrictive midwife laws in the country and is the only state where delivering babies without medical supervision is a felony.

“I think we’re totally backwards,” Skinner said. “Forty-three other states have passed more fair midwifery legislation. We are the only state where it’s called the practice of medicine. It’s just not right.”

Legislation introduced by Rep. Cynthia Davis, R-O’Fallon, which would have loosened midwife regulations, failed in the state Senate in the session that ended last month. The bill would have allowed mothers to choose the caregiver and setting of their choice in which to deliver and would have protected midwives from prosecution as long as a reasonable standard of care was administered. “I think that the women deserve to have their options open to them,” Davis said. “The bottom-line question is what’s in the best interest of the women who are making these choices?”

The legislation was opposed by several groups, including the Missouri State Medical Association and the Missouri Association of Osteopathic Physicians.

“It would allow absolutely anybody to license themselves out to the public as competent to deliver babies, with no requirements, no training, no certifications,” said Tom Holloway, a lobbyist for the Missouri State Medical Association.

“Nobody wants to have the responsibility of being at a birth and not know what they’re doing,” Skinner said. “I think (midwives) are very careful about getting the training that they need.”

Certified nurse-midwives are governed by the State Board of Nursing and must have a collaborative agreement with a physician within 30 miles in order to deliver babies.

Barnes has signed a settlement agreement acknowledging that she violated the Nursing Practice Act by collaborating with a physician, Dr. Christopher Jones of Springfield, who was not an obstetrician/gynecologist. As a general practitioner, Jones had not delivered babies since his medical school internship in 1987.

“Midwives should not be legislated this way,” Barnes told the Board of Nursing at her disciplinary hearing on Thursday. “I take care of normal births, not complicated births.”

Nurse-midwives in Missouri are only qualified to handle normal pregnancies. The collaborating doctor reviews patient charts to look for abnormalities that would indicate that the woman needs a doctor to deliver her baby. Also, midwives have transfer agreements with doctors so their patients can receive a physician’s care in case complications arise during delivery.

Barnes said that although she’s found plenty of doctors who will make transfer agreements, few will agree to collaborate as it requires them to travel to the clinic to review patient charts.

“As politics changed and hospitals bought up practices, physicians were no longer allowed to collaborate with midwives,” Barnes said.

According to the Missouri Hospital Association, physicians employed by hospitals are allowed to collaborate with certified nurse midwives. At Boone Hospital Center, which employs private-practice physicians, the decision to collaborate with midwives is left up to the individual physician.

Midwives must be certified by the American College of Nurse-Midwives in order to accept Medicaid patients.

Barnes said 78 percent of the clients at her birth center, WomanCare Inc. near Branson, are on Medicaid. She also serves members of a nearby Amish Mennonite community who do not have health insurance.

“In most parts of the state, they can either drive some distance to the doctor or they can stay home and go it alone. … Most people who do not choose hospital birth are forced to go it alone or hire an illegal midwife,” Skinner said.

One in six Missourians are without health insurance, Davis said.

“What are we doing to those women?” Davis said. “Their option is either put their family into debt by going to a hospital and paying perhaps 10 times the amount for a birth. The other choice is have a home birth with nobody there to help them. Our current law is more dangerous if someone were truly concerned with the health of the mother.”

Certified nurse-midwives may work in hospitals, birth centers, clinics or perform home births.

The state of Missouri has 99 certified nurse midwives, six of whom are in Boone County.

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Evelyn Cross May 5, 2009 | 10:01 p.m.

I can not believe that the MSMA is not up to date on such an important issue. Our so called practice of medicine has failed us more than once. I know very well how important it is to have the caring support of a nurse-midwife at a delivery, after all when I arrived at the hospital the doctor refused to deliver my child because she was with me. My midwife had to deliver a premature, stressed out baby because he would not. How is that for practice of medicine. Please give us a break. Write the state of MSMA and make your point.

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