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

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

Questionnaire for Midwives

Name ___________________________________________, License Number ____________

Address _____________________________________________________________________

Type of practice: ______ Domiciliary birth services, ______ Medical office or clinic,

______ Teaching, ______Inactive;    Other___________________________________________

Years of Practice  _________ Average Number of client families served annually __________

Check One:

Professional Liability Insurance ~ I have (or had) professional liability insurance covering community-based midwifery _____

During the time that I was covered by professional liability insurance I found my ability to make appropriate medical arrangements for my clients was substantially: (1) improved ______

(2) unaffected ______ (3) I was able to find legally-mandated physician supervision ______;

(4) I was NOT able to secure the cooperation of a physician supervisor despite insurance ______:

(5) I have been unable to find affordable malpractice insurance during the last 12 months ______

Comment: ____________________________________________________________________

Physician Supervison ~ ___ I am a provider of home-based birth service and I am able to meet technical requirements for physician supervision

___ As a provider of home-based birth service I am unable to find a physician supervisor but have appropriate alternative plans for medical interface in place

Physician Supervision is non-applicable due to (1) _____ inactive status (2) _______ Employed by a physician in a medical setting; (3) other _________________________________________

Check any/all of the following that apply to you:

(1) _____Before passage of the LMPA I was able to make satisfactory “back-up” arrangements for client families; 

After passage of the LMPA my ability to provide appropriate medical interface (arrange diagnostic testing, consult with a physician on a specific client/situation, refer to medical providers for care, transfer to hospital care) (2) _____ has improved greatly; (3) _______ is about the same; (4) _____ has gotten much harder, less satisfactory Brief Comment:  _______________________


Do you think that licensing under the current provision of the LMPA, which mandates physician supervision, serves to improve midwifery care and afford additional protection to consumers?

(5) Yes_____; (6) NO _____  (7) can’t say, undecided, etc ______________________________

Comment: _____________________________________________________________________


Since the implementation of the LMPA (Jan 1997) I have observed or been directly involved in patient care situations that were rendered unsatisfactory/unsafe due to the philosophical/political differences between Obstetrical Medicine and Community-based Midwifery by LMs:

(1) yes ____ (2) No ______ (3) can’t answer because ____________________________

If yes, this has occurred (4) _____ once or twice (5) ______  3 to 5 times (6) ______ 6 to 12 times (7) _____ greater than 12 Xs (8) _____ estimate of the times this included actual harm or introduced unnecessary or unnatural danger to mother or baby:

Please give 1 to 3 examples of this type of problem, focus on the most “usual” &/or most harmful:

(Add as many lines as necessary) ____________________________________________________________________ 

Since the implementation of the LMPA (Jan 1997) I have observed or been directly involved in patient care situations that resulted in threats against myself or my midwifery partner (1) ____ yes

(2) _____ NO; (3) Can’t say/doesn’t apply because ___________________________________

(4) _____ Estimate of times this included threats or reprisals against the LM

Describe / Comment: __________________________________________________________________________

Have you had a physician or hospital employee (i.e. non-family members) file a complaint with the Medical Board relative to home-based birth services (1) ____ yes (2) ____ NO (3) _____doesn’t apply

If yes:
(1) _____ Involved appropriate and timely hospital transfer with good outcome

(2) _____ Involved a problematic outcome that was not, in your judgment, the direct result of midwifery care in a domiciliary setting or a “quality of care” issue 
(3) _____ Involved a difference of opinion about “appropriate” scope” of midwifery care (for example a VBAC mother with appropriate informed consent/decline of standard medical care)

Describe / Comment: _____________________________________________________________(add lines as needed)

Since the implementation of the LMPA have you observed or been directly involved in providing care to a family that either had or planned to have a home birth in which the obstetrician or pediatrician was hostile to them, punitive in his/her treatment, triggered reprisals such as reporting the parents to CPS or refused to provide care due to their home birth plan?  (1) _____ yes; (2) ___ NO; (3) _____ Can’t say / doesn’t apply ________________

If yes please relate the specific of 1-3 of the most “usual” situation or the most egregious:

 (add lines as necessary) __________________________________________________________________________

Do you have any specific suggestions on how to improve the interface between midwife and physicians and between physicians and midwifery clients planning home-based birth care?

 (Add lines as needed) __________________________________________________________________________

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