California College of Midwives
February 17, 2000
Candice Cohen, Editor, Action Report
Medical Board of California
1426 Howe Ave
Sacramento, CA 95825
Fax 916 / 263-2387
RE: Submission article for Action Report
Thank you for considering submissions of articles for the Action Report relevant to midwifery topics. In order to avoid the “pending legislation” debate, I will express the information as relative to current law, which is in fact the case. These topics can be printed together or in two different issues. This submission a draft only.
Community-based midwifery care and access to medical Services
Midwives practicing under the Licensed Midwifery Practice Act have been unable to obtain direct physician supervision in regard to home-based midwifery care. The primary reason is fear by malpractice insurance carriers of vicarious liability litigation, even though to date there has been no such litigation against any obstetrician. Professional liability insurance is now independently available to licensed community midwives. Nonetheless, physicians in California have uniformly declined to participate as supervisors.
Irrespective to the concerns of malpractice carriers, 1% of California mothers continue to have their babies at home. This figure has remained unchanged for the last 30 years, apparently unaffected by the passage of the nurse and direct-entry midwifery licensing laws. While this represents a small fraction of babies born in the state, it still necessitates that skilled and competent care be provided to them and their mothers. Good care requires that each childbearing women have as much access to medical services as her circumstance allows and her family is willing to utilize. To that end California licensed community midwives make specific ‘working arrangements’ for each and every mother. Depending on geographical location and her health insurance or MediCal status (or lack of thereof) these arrangements generally fall into one of the following 5 categories and represent the various types of backup/referral/transfer of care, other “working arrangements” currently addressing the problem.
Mother-initiated / HMO -- The most mutually satisfactory arrangements are for families who belong to HMOs, especially Kaiser, as they simply see their HMO caregiver in early pregnancy for lab work and to create a hospital record of the pregnancy. These mothers subsequently receive the bulk of their antepartum, intrapartum and postpartum/postnatal care from the midwife. If there is any need for additional lab work or diagnostic tests they return to Kaiser. If a transfer of care during labor is necessary, the midwife simply accompanies them to the Kaiser facility and provides a report (and chart records) to the admitting physicians or nurse midwife.
Mother-initiated / Tandem or Concurrent Care-- Families with good healthy insurance coverage may arrange for concurrent care -- seeing an obstetrician through out the pregnancy, independently of the midwifery care.
Mother-initiated / Family Doctor -- A small number of client families have prior relationship with a family physician or obstetrician who is willing to see them occasionally during the pregnancy and has agreed to provide care for them in the hospital should they change their mind about laboring at home or should they need medical services.
Midwife-initiated Informal Arrangements with Specific Physicians - In some communities there are specific obstetricians willing to take referrals, occasionally consult by phone and will accept a transfer of care during labor. Most of these doctors do not want to see the patient ahead of time as that creates vicarious liability. They will only make themselves available in event of a transfer of care in which they had no prior contact with the expectant mother before she is admitted to the hospital.
Hospitals as Proxy -- In some communities there are such a small number of options due to geographical circumstances or resistance by the medical community to home-based midwifery that no physicians are willing to consult or accept a transfer of a mother who planned a home birth. In those communities families must agree to be transported to a specific hospital and cared for the resident staff or on-call physician in the event of an emergent circumstances for either mother or baby.
Also, this is the usual arrangement for families that ask for care under the religious exemptions clause (Sec. 2063). In these cases, physician supervision is not required. Many families asking for care under Section 2063 are only willing to accept medical services in event of an evident obstetrical or pediatric problem or an emergent condition and thus we use teaching or community hospitals as the identified source of medical services.
Information about California Licensed Midwives,
Home-based Midwifery Care and Timely Hospital Transfer
There is a lot of confusion and lack of information among the members of the medical community regarding the practice of California licensed midwives, the majority of whom provide home-based maternity care. A short update on the standard practice of California licensed community midwives may be useful.
In general licensed midwives and CNMs who provide domiciliary midwifery are equipped to provide the same quality of care to mothers laboring at home as would be available in a free-standing birth center or small community hospital and utilize a similar risk-screening protocol. Midwives are present full time during active labor to monitor both mother and baby. Unless the family objects they routinely use a doptone and intermittent auscultation, which is a method of fetal surveillance approved by ACOG and considered equally effective as EFM for low-risk pregnancies. Other equipment includes the usual blood pressure cuff, stethoscope, sterile gloves, IV fluids, anti-hemorrhagic drugs, O2 and neonatal resuscitation equipment.
A few midwives carry a laptop-size electronic fetal monitor recently marked here by a UK company which retails for about $2900. It has an upgraded circuitry and auto-correction and is used intermittently during home labors to document normal fetal heart tones and provide EFM tracings in case of hospital transfer. Some midwives also have pulse oxymetery for maternal and neonatal use should there be a question of wellbeing. About 1/3 of community midwives in California carry professional liability insurance through a master policy. In the 18 month history of this group plan, there have been no claims filed.
Skillful midwifery care includes a responsibility on the part of the midwife to make timely transfers of care whenever the family requests it or if the course of labor is not progressing appropriately or indications of a problem are present. In those cases, the midwife, in conjunction with the family, concluded that they would be better served by hospital-based obstetrical care and initiated a timely elective transfer.
“Failed home birth” Vs. Timely elective transfer -- an important distinction
The topic of medical care for midwifery clients is especially controversial in regard to elective intrapartum transfer of a laboring mother or her neonate postpartum. Often the medial chart for mother or baby is marked “Failed home birth”, which sometimes leads to prejudicial aspects of care, either during the labor or afterwards for the baby. The mother is frequently assumed to be medically non-compliant, an assumption which is rarely accurate. The parents and the midwife usually view this transfer of care quite differently. For them it was not a “failed home birth”, but rather a timely and elective transfer of care. This usually occurs during first-stage labor -- not second stage (i.e.., the actual birth) -- because the mother’s labor was not progressing at home, she changed her mind about having an unmedicalted labor, wants epidural anesthesia or some potential or actual complication has arisen making hospital care desirable. This is how the system of medical interface is supposed to work between the disciplines of medicine and midwifery. It is not a “failed” home birth but rather a “relocated” labor and birth based on medical indications. or maternal desire. It means the midwife was doing her job well and the parents were intelligent, cooperative and conservative in their concern for the baby’ welfare.