Dr Fantozzi, Chair, Midwifery Committee
Medical Board of California / DOL1426 Howe Ave Suite 54
Sacramento, Ca 94303916 / 263-2365
California College of Midwives
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491June 24, 2004
RE: Midwifery Committee Meeting May 6, 2004
Synopsis of topics in this correspondence:
(1) Kill-Bill ~ Notification to the MBC of a request by the California College of Midwives and California Citizens for Health Freedom to Senator Liz Figueroa to either repeal the supervision / standard of care provision of SB1950 or pass remedial legislation statutorily defining the appropriate standard of care for LMs to be an evidence-based midwifery standard as used by the California community of profession midwives and supported by the scientific literature
(2) To inform you that a 2 notebook set of scientific literature on physiological principles, midwifery practice and intrapartum management in domiciliary settings will be provided to you at the next Midwifery committee meeting. A second set will also be presented to the MBC staff, along with the California College of Midwives’ ‘Blue book’ of Generally Accepted Practices (GAP) [Note: Dr Karlan already has a copy of the scientific literature 2-book set]
(3) To express the belief by the California community of midwives that all members of the MBC directly involved in making decisions (voting, etc) in regard to the practice of licensed midwives have a due diligence obligation to be knowledge of the information presented in the scientific literature, including the fact that there is a broad consensus of scientific data supporting the social model of maternity care in domiciliary setting -- a safe and cost-effective method that depends on the use physiological principles and a minimally interventionist style used by midwives and a few family practice physicians
(4) To identify an effective political/legal responses by the College of Midwives and CCfHH to address and correct the underlying problem -- the dysfunctional politics of organized medicine relative to topics of maternity care for healthy women with normal pregnancies.
Dear Dr. Fantozzi,
I want to personally acknowledge all your hard work as a MBC member. I know that chairing the Midwifery Committee is difficult and unpopular, a sure way not to make many friends. I and other licensed midwives thank you for becoming familiar with the messy aspects of this political controversy.
I know you are still wondering whether community-based midwifery represents a solid, science-based form of maternity care or a dangerous hippie cult. The burden of responsibility as a physician and a voting member of the Medical Board must create quite a crisis of conscience in regard to this matter. I assure however, that the more you know, the more you will be convinced that physiological management is the evidenced-based model of maternity care. It is associated with the lowest rate of maternal and perinatal mortality, is protective of the mother's pelvic floor, has the best psychological outcomes and the highest rate of breastfed babies. Use of physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative complications, delayed and downstream complications in future pregnancies.
By comparison, conventional obstetrics as applied to healthy women is the opposite of evidence-based, physiological management. Its associated with high levels of medical intervention, obstetrical complications, anesthetic use, instrumental deliveries, Cesarean surgery and post-operative complications including emergency hysterectomy, delayed complications such as stress incontinence and pelvic organ prolapse, downstream complications in future pregnancies such as placental abnormalities and stillbirths, long-term psychological problems such as postpartum depression, lower rates of breastfeeding and increased rates of asthma in babies born by cesarean section. Conventional obstetrics for healthy women is neither safe nor cost-effective.
A long over-due, and much needed reform of our national health care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. Physiological management should be the foremost standard for all healthy women with normal pregnancies, used by all practitioners (physicians and midwives) and for all birth settings (home, hospital, birth center). This “social model” of normal childbirth includes the appropriate use of obstetrical intervention for complications or at the mother’s request.
Due to the historical agenda of organized medicine to discredit physiologic principles and the conventions of tort law, midwives are currently the only professional maternity care providers that are trained, skilled, experienced and legally able to provide physiological management for healthy women with normal pregnancies. An ethical response to this dilemma would trigger ACOG policy reform, which would prompt medical schools to teach the philosophy, principles and skills of physiological management to medical students, practicing physicians to learn and use the strategies of physiological management and insurance companies to reimburse obstetricians for this safe and cost-effective care.
As you well know, this is differently not happening. Instead, healthy childbearing families, hospital-based nurse midwifery programs and professional midwives of all backgrounds face extremely serious problems under our highly politicalized and deeply dysfunctional obstetrical system. The many controversies currently bedeviling the licensed midwifery program are only symptoms of this dysfunction system.
The underlying Issues
The MBC and its midwife licentiates are both being held hostage by this dysfunctional system. This political situation is beyond the scope of either midwives or the Medical Board to remedy or even to address directly. The actual problem is the historical agenda of organized medicine to gain control over the provision of all forms of health care and to fight against all non-physician practitioners. Neither the Medical Board nor the California College of Midwives can require the cooperation of these groups or block their political influence. Medical associations are obviously exercising their constitutional rights – unfortunately, its much to the public’s detriment. For nearly a hundred years, this situation has been negatively influencing midwifery practice and its regulation by state governments, and still no end in sight.
The Medical Board’s response to threats of litigation by the CMA and ACOG appears to be a strategy of indefinitely postponing definitive action on controversial midwifery-related agenda items. The tone of the last Board meeting reminded me of the 1950s peace talks between North and South Korea – they spent the first two years arguing about the shape of the table and never actually were able to bring an end to the war. Permanent stalemate is the name of that game.
Such a stalemate applied to this situation brings up the specter of one or two (or more!) years of legal wrangling, with many contentious meetings, regulatory hearings scheduled, prepared for, postponed, testimony solicited, rule-making files produced, letters back and forth to the Office of Administrative Law, etc ad nauseum. This is a needless expenditure of valuable time, talent and money for the Board and for the midwives -- all to no avail.
A better Way --
It seems that the midwives have only two viable options -- either reiterate the style of the CMA by also threatening litigation or taking action to address and remedy the real or underlying problem. We like and respect the members and staff of the Medical Board and find the idea of suing one’s regulatory board to be both repugnant and counter-productive. Happily we have chosen the latter option -- tackling the real problem. This permits our group to use those same resources of time and talent to advance the interests of the public, the success and safety of the licensed midwife/client relationship, to resonate with the public safety mission of the MBC and to facilitate the Board’s ability to do their regulatory job with grace and efficiency.
(A) To achieve these goals we have asked Senator Figuero’s office staff for a “Kill-Bill”, that is, to approach the Senator with our request to either kill or remedy the provision of SB 1950 that is currently causing such a major problem for both midwives and the Board. It seems prudent for the Medical Board to put any comparison studies relative to hospital-based obstetrical standards and midwifery management on hold until the Senator responds to our request, one way or another.
(B) We have created a new and broadly-based consumer organization – the Consortium for the Evidence-based practice of Obstetrics or “CEO”. The web site is www.ScienceBasedBirth.com. The purpose of CEO is to bring the attention of the public and the legislature to the profoundly dysfunctional nature of our current obstetrical system. The routine application of interventionist obstetrics on virtually all healthy women introduces artificial and unnecessary harm. At present, the obstetrical profession systematically fails in its most important job -- to preserve and protect already healthy childbearing women..
Our first activity is a letter writing campaign – our goal is a 1,000 letters in a 100 days to California First Lady Maria Shriver. The direct purpose of this activity is:
1. To create a cohesive, broad-based and effective constituency made up of consumers, taxpayers, childbirth and public health professionals committed to reforming our national maternity care policy
2. To bring about legislative hearings on the issues identified in the CEO White Paper, including the off-label use of Cytotec for labor induction, the ever-climbing cesarean section and maternal mortality rate, the danger in promoting the maternal choice cesarean as the so-called ‘ideal’ form of childbirth and the physically damaging effects on the integrity of the pelvic floor and pelvic organs associated with the current, medically-interventive management of vaginal birth
3. To facilitate passage of legislation mandating that physicians obtain true informed consent before substituting medical and surgical interventions in place of the safer, evidence-based principles of physiological management and that they provide full information about the risks of medical or surgical intervention and obtain consent before implementation.
Conclusion
Speaking on behalf of mothers and midwives both, we believe that the only way to resolve the intractable licensing and practice issues noted earlier is to fundamentally change the public discourse between women and ACOG. This is to be accomplished by first winning in the court of public opinion and then, if necessary, in a court of law and finally in the legislature. The law must changed for both midwives and obstetricians.
The 'physician supervision clause' in the certified nurse-midwife and licensed midwifery acts must be repealed. It creates unnatural and unnecessary vicarious liability for physicians, which totally blocks their ability to appropriately consult with midwives or provide necessary hospital care for midwifery clients. CMA lobbyists promised the Legislature that a licensing law requiring physician supervision would promote public safety by guaranteeing appropriate access to medical services by pregnant women. Instead of the promised stepping-stone, this provision of the LMPA turned out to be a stumbling block, which creates unnecessary and unnatural hazards.
The only solution is for midwifery to be an autonomous profession. The current unworkable relationship between physicians and midwives must be replaced with a voluntary one defined as 'collaborative', in which midwives consult with physicians as needed and are respected by medical and obstetrical providers as colleagues.
Until the LMPA is appropriately amended, the Medical Board will be unable to do its regulatory job with either grace or efficiency in regard to licensed midwifery and LMs will continue to be denied the simple human dignity of being able to be in compliance with our licensing law.
I look forward to seeing you at the next Midwifery Committee meeting on July 29th.
Faith Gibson, LM, CPM,
Executive Director, American College of Community Midwives
Coordinator, California College of Midwives (ACCM state chapter)Cc: Senator Figueroa’s office
MBC DOL Linda Morris
Frank Cuny, Director, California Citizens for Health Freedom
Megan Roy, CAM // MBC Liaison