Midwifery ruling: 'an unfair treatment' of rights?

Tuesday, July 31, 2007 | 2:00 a.m. CDT; updated 3:46 p.m. CDT, Tuesday, July 22, 2008

COLUMBIA - Expectant mothers Kimberly Fallon and Dallion Rehm were planning to take advantage of a new state law by giving birth at home, using certified professional midwives as their primary caregivers.

But Fallon, who is expecting her fourth child in October, and Rehm, who is expecting her third child in January, are worried that when it comes time to deliver their babies, the only legal option may be a hospital.

The new law, which reverses a long prohibition of the practice of midwifery in Missouri, was scheduled to go into effect on Aug. 28. But on July 3, a Cole County judge issued a temporary restraining order that prohibits it from taking effect.

“It’s an unfair treatment of my rights as a citizen for the state to tell me who can be present at my birth,” Rehm says. “I’m an intelligent person, and I made my choice carefully, without compromising any standards of safety.”

The legal complications stem from the addition of a midwifery provision added to an insurance-related bill in the Missouri house that allows anyone certified in tocology — the science of childbirth — to provide services related to pregnancy, including midwifery.

The provision was added to the House bill by Sen. John Loudon, R-Chesterfield, who was the chairman of the Senate insurance committee. At the time, a bill that would have legalized midwifery outright in Missouri — a bill that had received the first of three majority votes required for passage — was being filibustered by Sen. Chuck Graham, D-Columbia, and Sen. Yvonne Wilson, D-Kansas City.

Loudon’s addition to the insurance-related bill so angered his colleagues that he was temporarily removed as chairman of the insurance committee. Graham, a vocal opponent of the original midwifery bill, called Loudon’s tactic of employing the rarely used word “tocology” instead of directly referring to midwifery as “deceitful.”

Then, in late June, a coalition of physicians, led by the Missouri State Medical Association, filed suit challenging the legality of Loudon’s provision on grounds that its addition violated Missouri’s constitution, which states that the content of bills must remain true to their original purpose, have a clear title and not contain multiple subjects.

Cole County Circuit Court Judge Patricia Joyce is scheduled to hear arguments on the case at 9 a.m. Thursday in Jefferson City. Midwifery advocates plan on holding a courthouse rally at the same time.

“A lot of people are critical of the tactic that I used, which is perfectly constitutional and not atypical,” said Loudon, who accused Graham of “polluting” the political process by filibustering a bill that had majority support.

Though the hearing will focus on whether the addition of Loudon’s provision was unconstitutional, the legal issue appears to be a stand-in for the deeply held convictions of midwifery supporters and opponents.

Loudon has personal reasons for his support. When his wife, who has had two miscarriages, became pregnant again, a midwifery advocate suggested a type of testing that her obstetrician never mentioned.

“It turned out that my wife had a problem she was able to deal with, and now we have a child that I’m convinced we wouldn’t have if it weren’t for this midwife advocate,” Loudon said. “Although we’ve always had hospital births, (midwives) helped me, and I sure wasn’t going to turn my back on them.”

But some say Loudon’s provision opening the door to midwifery in Missouri could end up harming women. Unlike previous midwifery bills, the insurance-related bill — HB 818 — did not establish a state oversight board.

Jeff Howell, the state medical association’s director of legal affairs, says that without government oversight, the two organizations that offer tocology certification — the American College of Nurse-Midwives and the North American Registry of Midwives — could change their training requirements without consulting the state.

“This delegates training and licensing to an outside group,” he said. “Any other licensed professional, whether a cosmetologist or veterinarian, goes through licensing boards that are part of the state government.”

Debbie Pulley, spokeswoman for the North American Registry of Midwives, or NARM, said she would support legislation that provides oversight. But she denies charges made by some physicians that certified professional midwives don’t have enough training.

Certified professional midwives must attend a minimum of 40 births and act as the primary midwife in 20 of those births; at least 10 must be in out-of-hospital settings. In addition to passing a written exam, midwives must demonstrate proficiency in some 750 hands-on skills and complete 1,350 clinical hours of training with another certified professional midwife. The certification process takes three to four years to complete. Nurse midwives, who are allowed to practice in Missouri under a separate statute, usually undergo six to seven years of training and must meet accredited standards in nursing as well as midwifery. They are required to pass national board exams and have a bachelor’s degree.

Mary Ueland, chair of the Missouri Midwives Association, argues that while nurse midwives learn about broader topics such as geriatric care, they are no better qualified to practice midwifery than certified professional midwives. “Certified professional midwives may not be as diverse in other fields, but they have the same body of knowledge and skills for birth as nurse midwives,” she said, noting that nurse midwives are not required to train in out-of-hospital settings.

About 90 nurse midwives are certified in Missouri, but only two provide home births. This makes it difficult for women, particularly those from rural areas, to have legal home births. Pulley said passing HB 818 was important because women who are pregnant now should be able to choose where they give birth without waiting through more legislative delays. Making midwifery a felony — which Missouri law did before the passage of HB 818 — puts more women in danger, she said, because they may choose the legal option of having a birth at home without the aid of a midwife.

But Tom Holloway, spokesman for the Missouri State Medical Association, doesn’t agree with that logic.

“In most cases, a certified professional midwife would be safer than no midwife at all, but that doesn’t mean that it’s safe enough for the state to sanction,” he said.

Both sides of the issue have used data on home births to bolster their arguments. Opponents cite a University of Washington study that showed infant mortality rates for planned home births in Washington state between 1989-1996 were twice as high as the hospital infant mortality rate. Advocates cite a 2005 study published in the British Medical Journal that found that, among low-risk women, infant mortality rates for planned home births in the United States and Canada are similar to infant mortality rates for hospital births. Home births also required less medical intervention, according to the study.

Home births attended by a midwife are typically much less expensive. Fallon estimates it will cost about $2,000 to deliver her baby with a midwife, including prenatal and postpartum care. At Columbia Regional Hospital, a single vaginal birth with no prenatal care, overnight stays or anesthesia costs $8,884.

While some midwifery advocates say the medical establishment’s opposition is based on preserving its economic advantage, it’s unlikely that Missouri hospitals will experience a sharp decrease in deliveries if the law is upheld. Nationwide, less than 1 percent of babies are delivered at home or in birth centers, according to a 2006 Centers for Disease Control report.

Although a small percentage of families will be affected by the outcome of this week’s hearing, the issue is close to the heart for women like Fallon and Rehm, both of whom have given birth in a hospital setting and at home.

Rehm recalls that, during her home delivery, the only people in the room were her husband and son, a midwife and the midwife’s assistants, compared with the 17 people she said attended her hospital birth.

One thing the new provision does not address is a law that prohibits Missouri physicians from assisting unlicensed practitioners, such as midwives, in providing medical services. Howell says that, under current law, attending a birth is a practice of medicine. Because midwives aren’t licensed by the state under the new law, he said, assisting with a delivery would be practicing medicine without a license. And a physician advising or assisting a midwife could lose his or her license.

Rehm isn’t sure what she’ll do if the law is struck down. Now that she’s spoken publicly, she worries that she may need to “go undercover” to deliver her child at home. Rehm — who didn’t want the name of her hometown published — also worries she will put her midwife at risk.

“If I’m in that tiny group of people that end up needing medical transport, I want to be able to walk in (to a hospital) with my husband and midwife and say, ‘This is what happened, this is what’s going on,’” Rehm said. “If my baby’s life is at stake, I don’t want to be distracted by the legality of my midwife.”

Fallon, who is from Lake St. Louis, isn’t as concerned. She says that even if the court strikes down the new law, she will carry on as planned.

“Whether or not the injunction is upheld doesn’t disqualify my midwife,” she said. “She still has the same training, and I have the same confidence in her.”

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Tracey Moore August 1, 2007 | 9:52 a.m.

Thank you Molly for this clear and well balanced article. I appreciate your thoughtfulness in your presentation, and your clear writing!
It is truly backward of Missouri to make qualified Midwives felons for helping families, when they are welcomed legal health care providers in so many other states!

(Report Comment)
Kristin Effland August 5, 2007 | 11:43 a.m.

I think it is important to point out that the study to which midwifery opponents refer in Washington State, also known as the Pang study, has been challenged as inaccurate by several reputable authors in peer reviewed journals. The Pang study is inherently flawed because it is a RETROSPECTIVE study using birth certificate data. At the time of the Pang study in WA, birth certificates did not even include information about whether home births were planned or unplanned. This is significant because unplanned home births are not attended by qualified health care professionals and have been shown by numerous studies to pose increased risks.

On the other hand, recent research, namely a PROSPECTIVE study published in the British Medical Journal, demonstrates that Certified Professional Midwives (CPMs) safely attend home births in North America. Because CPMs are adequately trained to attend healthy women in labor as well as recognize and treat complications that can but usually don't arise, planned home births attended by CPMs are not only a safe alternative but also confer measurable benefits which is one reason why women choose the option.

(Report Comment)

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