Reporting Inappropriate or Unsatisfactory
 Medical Interface, Unwarranted Disciplinary Actions, etc

Navigation Key: LM Questionnaire for MBC Report  ~   Parents Form for MBC Report (not posted yet)

We need to enlist the help of the Medical Board and Senator Figueroa’s office to properly address problems of inappropriate, unsatisfactory medical interface arrangements (inability to consult or refer clients to physician care, problems with hospital transfer, etc) through better education of medical caregivers, through use of current avenues of complaint and investigation of physicians and perhaps, the passage of new regulations or legislation and perhaps even a legal action. 

In order to do that, we must be able to document the nature and magnitude of the problem. In August of 2000 the Senate Office of Research developed a survey of midwifery practice. It documented many of these problems, most especially the general inability of licensed community midwives to find the mandated physician supervision. However, that data is now 2 ½ years old. Also the situation has gotten worse during that time. What we need now are first-hand accounts of the breakdown in medical interface from two sources – midwives and the mother or other family members. Enclosed are two forms – one for the midwife and a photocopy original to be reproduced in larger quantities and distributed to client families. Please note that the client/family version includes such problems as finding suitable pediatric care relative to the plans for a home birth. Some families are being told on the phone that a pediatric office will not take care of anyone who delivers at home. Others have found themselves being forced into unwanted medicalization under treats of being reported to CPS. All of these issues need to be addressed.

It is so important that we be able to collect this type of information that we have designed the forms allow for three different levels of privacy –

(1)   Yes, I can attest to the following events but I am unwilling/unable to supply the names of individuals (for example midwives who fear reprisal by local doctors or families that fear being harassed by the CPS if the offending individual is confronted). 

(2)   Yes, it happened and while I am willing to provide names if absolutely necessary, I’d strongly prefer not to ‘name-names’.

(3)   Yes, here is the name of the doctor/hospital and the dates of the incident.

The form for midwives is initially a general accounting of events occurring since the implementation of the LMPA in 1996. This includes all varieties of refusal by physicians to either consult with the midwife or to provide timely care to the mother or baby or to have provided punitive and inappropriate care such as “automatic” cesarean. It also includes reporting any action taken against the midwife by the MBC that was the direct result of obstetrician hostility. In particular, we need to have records of cases in which involve an appropriate transfer of care with a good outcome in which the physician took umbrage about some aspect of midwifery care or home birth plans and filed a non-meritorious complaint.

This midwife report form is also accompanied by a California College of Midwives Incident Report that should be saved to document future incidents. It is important that LMs report every additional incident of this nature. The CCM forms come to me at the above address and I mask the LMs name before photocopying and sending on to the MBC consultant, Dr. Pat Chase. Please use only initials of the client family and it is up to you as to whether or not to use the name (versus initials) of the physician, nurse, EMT or other medical provider. Personally, I suggest the use of initials unless you are contacted directly by a member of the Medical Board and asked for the offender’s full name. 

The form for mothers/other family members generally covers the experience of discrimination or substandard care because of their association with a midwife caregiver or due to lawful but medically unpopular choice relative to childbirth - for example being turned down by pediatricians because they gave birth at home or had a hospital transfer from a planned home birth. The same appreciation of privacy is provided for this questionnaire, so as to protect parents from recriminations.

Please fill out and return the LM questionnaire ASAP. Politically speaking, we are dead in the water until we can get this information and present it to the MBC and Senator Figueroa’s office. 

Photocopy the parents questionnaire and distribute that ASAP and return to CALM any responses as quickly as possible.

Mail to: CALM, P.O. Box 620191, Woodside, CA  94062-0191

Help the MBC understand the "Backup arrangements" currently used by LM
This helps us prevent inappropriate disciplinary actions by MBC,
related to physician supervision issues 
~ Overview & Background Information

1) SB 1479 – Official Documentation of Medical Interface Arrangements 

At present, these “Arrangements for Medical Interface” are officially documented in a form prescribed by SB 1479 (Figueroa Amendment to the LMPA), in which the midwife and client together identify exactly what the arrangements are for medical care during (1) pregnancy, (2) the intrapartum, (3) emergency care for mother and/or baby at or following birth at home. By law, this is an official part of the client’s chart.  

Unfortunately, the political opposition to home-based midwifery care by obstetricians and pediatricians and prohibitions from malpractice carriers has been eroding these historic avenues for obtaining preventive and essential medical services. Since implementation of the LMPA in 1996 the interface between licensed midwives and the medical community has been in an ever-downward spiral. A significant number of midwives report being turned down in all efforts to consult with physicians or to able to make arrangements for appropriate diagnostic services (sonograms, NSTs, bio physical profiles, etc). Those with good arrangements see them devolving to less and less satisfactory levels. Many report outright hostility and even threats of being reported to the medical board. Several cases currently being pursued by the medical board against LMs were the result of just this type of hostility, in which an appropriate hospital transfer occurred with a good outcome but the midwife was reported by an irate obstetrician or perinatologist for a variety of supposed offences –most usually the fact that she did not have physician supervision.

In the past 3 years, there has been one documented case of a preventable antepartal fetal death due to the unified refusal of all medical providers in a small community to provide access to NSTs for a post dates mother. There have been two separate incidences of obstetricians performing medically unnecessary and unwanted Cesareans (instead of the more appropriate oxytocin augmentation) because “they only did CSs on home birth transfers”. Recently a pediatrician called the police on a home birth family that transferred to a Kaiser hospital intrapartum. After a normal birth/healthy baby, the mother wanted to go back home to the couple’s 3 other children. Gun-toting police officers sat in a chair by her door to prevent her from being discharged until 6 hours later when the pediatrician decided he’d made his point. 

Midwives regularly relate stories of foot-dragging in which obviously necessary tests or treatments are postponed hours or even days because it involves a pregnant or laboring woman who had planned a home birth with a midwife. Many midwives have been present when a mother was treated punitively because her association with home-based midwifery, for instance unnecessary episiotomies were performed or the doctor refused to use local anesthetic when suturing. Sometimes Cesarean are performed for babies with a minor deviations of the EFM strip, such as normal head compression decals but with good recovery and good variability.

Overall the fair measure of safety for home-based birth services as provided by a skill and experienced professional with access to appropriate medical services for complications is equal or superior to that of hospital-based care. However, refusal of the medical community to provide timely access to essential, preventative and at times, emergent care actually provokes the very dangers they say they are trying to avoid and makes home-based care artificially riskier. This must be stopped as soon as possible, both for the sake of childbearing women and their babies and because it is generally unethical. It represents an “unfair business practice” in which a competing entity with a state-sanctioned monopoly discriminates against a competitor. This is illegal.   

(2) Physician Supervision Problems and so-so Solutions

The LMPA of 1993 mandates that licensed community midwives practice under the supervision of a physician. However, in the 9 years since the passage of the Midwifery Practice Act, physicians have uniformly refused to provide such a formalized relationship, often citing a malpractice insurance policy that prohibits such relationships. This inability or unwillingness on the part of obstetricians to be professionally associated with midwives was legally acknowledged by Judge Roman in the Alison Osborne Decision. He cited both liability concerns on the part of physicians and a general hostility to home-based midwifery by obstetricians as the reason that midwives cannot comply with the technical requirements of the law. 

Since LMs are unable to have formalized arrangements, we continue to use the web of “backup arrangements” that were common before professional licensing for direct-entry midwives was available. This includes informal consultations between a midwife and physicians in her community and the various independent relationships between the client and private physicians or resident staff of teaching hospitals. For the last 30 years community midwives have been making these 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 

            Mother-initiated / HMO -- The most mutually satisfactory medical interface arrangements are only available to families who belong to HMOs, especially Kaiser, as they see their HMO caregiver in early pregnancy for lab work and to create a hospital record of the pregnancy.  If a transfer of care during labor is necessary, the midwife simply accompanies them to the Kaiser facility and provides a report (and intrapartum chart) to the admitting physicians or nurse midwife. HMOs likes this as it save them money.

            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.  Now days this must be a “don’t ask, don’t tell” arrangement.

            Mother-initiated / Family Doctor -- A small number of client families have prior relationship with a physician 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 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 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 are usually somewhat underground about these relationships with midwives and midwifery clients.

            Hospitals as Proxy -- In some communities there are such a small number of options due to geographical circumstances or hostility by the medical community 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.