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Letter to
the Editor ~ criminal prosecution |
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March 19th 1998 Dwight Sparks, Editor, Davie County Enterprise Record RE: Reversing the unscientific principles which currently are
the Dear Mr. Sparks, I am the executive director of a professional organization
for physicians and midwives who provide “domicilairy” or
out-of-hospital (either home or birth center) maternity care.
Our organization seeks to “normalize” midwifery (and thus
maternity care) in the US by freeing midwifery from popular prejudices,
legislative encumbrances, legal bias, and most recently, the
criminalization of midwives so that midwifery can be restored to its
traditional place as an honorable and independent profession with a
central role in a national maternity care system.
The core of the problem for mothers, midwives and tax
payers is the uncritical acceptance of unscientific principles as the
foundation for maternal-infant health policies in North America.
A quote from the 1963 edition of Davis Obstetrics
says it quite well: “There
can be no alibi for not knowing what is known”. Evidence-based
practice parameters are the future of maternity care in North
America and they identify the midwifery-model of care for normal
pregnancy as the ideal based on proven safety and cost-effectiveness.
That ideal includes voluntary access to domicilairy birth services
for healthy mothers who choose to be cared for in homes or birth
centers by skilled midwives or physicians and easy access to
hospital-based obstetrical services for complicated pregnancies or
mothers who desire medication or require anesthesia during the labor or
birth. The safest form of midwifery is that which is well-articulated
with obstetrical services and the safest form of obstetrical service is
that which is integrated with the midwifery model of care. World-wide maternity statistics testify to the superior outcomes for both mothers and babies of midwifery care, liberal breastfeeding, female literacy, valuing the parent-child bond and access to obstetrical medicine for complicated pregnancies. For the better part of 2 centuries during which data is available these common-sense methods have been strongly associated with both good outcomes and low rates of mortality and morbidity. They are the lynch-pin of cost-effective healthcare for childbearing families as financed by governments and other third-party payers. Many of us believe that it is simply unacceptable as citizens of a democracy to continue supporting a maternity care system that systematically ignores more than a 100 years of factual data identifying independent midwifery management for normal birth as the only safe and cost maternal-infant national health policy for the 21st century. In light of this overwhelmingly positive data, it seems
only fitting that the valuable contribution of skilled midwives
currently practicing in North Carolina be recognized and preserved
through the creation of a state licensing mechanism. I would like to
recommend to your legislature that same type of direct-entry midwifery
licensing adopted in the ‘Licensed Midwifery Practice Act of 1993’
by the state of California. Educational and training standards for
direct-entry midwives were set to be “equivalent but not identical to
those required for certified nurse-midwives”. This provision creates a
single body of knowledge which helps to defuse the resistance from the
medical and nursing community who oppose what they consider to be a
substandard classification of midwifery licensure. This Midwifery Practice Act includes a “challenge”
mechanism which permits experienced midwives to demonstrate their
competency and become licensed. To qualify one must be able to document
235 discrete caregiver activities (95 antepartal exams, 40 labors, 20
deliveries, 20 newborn exams, 80 postpartum and neonatal exams and
family planning visits). Only
after successfully meeting this criteria can a practicing midwife
preceed with the challenge mechanism which is administered by the
Seattle Midwifery School (an accredited 3 years midwifery training
program in Washington state). Then each midwife must successfully
passing an extensive six hour written exam as well as an eight hour
clinical demonstration of midwifery skills and finally, the passage of
an eight hour state board. She must also become certified in neonatal
resuscitation and advanced CPR and participate in 36 hours of continuing
education per 2 year licensing cycle. As you can see the Licensed Midwife challenge mechanism is
very rigorous (in fact it was written by the California Medical
Association). Community
midwives licensed under such as plan must
meet national standards which reflect those set by the North
American Registry of Midwives(NARM). A midwife who qualifies for this
professional credentialing process by NARM is known as a “Certified
Professional Midwife” (CPM). California
uses the NARM credentialing exam as its state licensing board. North
Carolina midwife Amy Medwin is a Certified Professional Midwife who
meets these same national standards of experience and has passed the
NARM midwifery board and thus would qualify for this licensing process
were she a resident of the state of California. I would strongly urge your paper to investigate the factual
basis of the information in this letter. You may access a great deal of
historical and contemporary material without having to do an equally
large quantify of “leg-work” by visiting our web site at <http://www.goodnewsnet.org>.
In particular, I suggest reading the file that appears at the top
of the frontpage entitled “The Official Plan to Eliminate the
Midwife”. It will give you the historical background of the
Hundred Years War against midwives by organized medicine. Of course,
there are many other interesting files with statistical and scientific
data which support the principles of a midwifery model of care and the
safety of domiciliary birth services when rendered by skilled
practitioners. After having completed this phase of verification, I hope
that your paper would be an outspoken advocate of a direct-entry
licensing mechanism for North Carolina. State licensing would make
cost-effective domicilairy midwifery care available to the childbearing
population of North Carolina, maximize consumer protection by providing
competency-based licensure and would remove the onus of criminalization.
In addition, state-licensed community midwives of all educational
backgrounds (both CNMs and CPMs) now have access to affordable liability
and malpractice insurance with 1 million/3 million dollars coverage (the
industry standard) through a nationally-based master policy. This not
only increases the safety net to consumers but makes the economical
services of domicilairy midwives available through HMO and PPO insurance
plans, helping to control the costs and increase the profitability to
the insurer. Clearly this is a win-win opportunity which is particularly
valuable from the standpoint of reducing the expense of maternity
services while improving maternal-infant outcomes. At present, the maternal-infant statistics for North
Carolina reflect some of the highest mortality and morbidity in the
country. Affordable and efficacious midwifery care would contribute to
significantly improved outcomes (especially reduction in prematurity
which is a costly condition to treat!)
while reducing the burden to tax payers, employers and private
citizens. In an expanding global economy, in which we are competing
against the 66% to 80% of the world already taking advantage of this
economical form of maternity care, it is not a trivial matter that we
are 23rd (that is third from the very bottom) in perinatal
mortality while spending the very most per capita and having one
of the very highest cesarean section rates in the world (second
to Brazil). Obviously we are not getting our money’s worth or meeting
the practical needs of mothers and babies. The double whammy of higher insurance premiums to
corporations and individuals and expenses of the medically indigent born
by governments must then passed on in the price of the product -- thus making
us less competitive globally and/or resulting in the exporting of
jobs abroad. While
rehabilitation of our national maternity care policies are not the final
answer to all the pressures of the globalization, it would at least help
us to reverse the trend toward ever-high healthcare costs and would do
so while improving performance. Currently, hospitalization for normal
childbirth is the number one diagnosis county-wide and the number one
diagnosis for the federal Medicaid program. When one considers that
healthy mothers are not sick and normal childbirth is not a disease, to
have childbirth be the number one cause of hospitalization is a
startling statistics. Money used for expensive and unnecessary
hospitalization of well women displaces that available for ill, injured
or elderly people. This is an additional reason that our national
maternity policy is of concern even to those who are not personally
involved in utilizing birth services. No one expects that domiciliary
care would ever replace hospitalization as the dominate form -- for
instance it is only about 33% in Holland, the industrialized country
with the highest per capita rate of domiciliary confinements (and top
five in perinatal statistics!). However, with trained and licensed
community midwives and a good system of obstetrical backup, we could
easily reduce unwanted hospitalization by perhaps as much as a third.
Truly this is worth the investment of our time and attention to
bring about. In closing I wanted to mention that I moved from Gibson, NC
(15 miles west of Laurenburg in Scotland country) to California in 1979.
I plan eventually to return to North Carolina, which is certainly
God’s country. Wouldn’t
it be lovely if reciprocity of licensure was available as I would be
honored to serve the childbearing women of North Carolina as I have
those in my adopted state of California. I look forward to your reply. Faith Gibson, LM, CPM Executive Director, ACDM cc:
Ina May Gaskin, President of the Midwives Alliance of North
America
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