Jan 2005

Yahoo CAM region 3 group – January 2005 emails regarding MBC/Standard of Care // CCM controversy

From: Diane Holzer <midwife@l...>
Date: Wed Jan 12, 2005 12:31 am
Subject: standards

I also had a good talk with our lawyer today regarding this whole thing, he talked with Carrie today also and he is feeling uncomfortable with us even agreeing to any of the document. he maintains that other providers don't have regulations like those and that we shouldn't either. We are screwed in a civil suit. well we may be screwed anyway but for sure if we haven't followed a written guideline........he is not sure we should even go along with it at all but of course will
bend to our will..............diane

From: Diane Holzer <midwife@l...>
Date: Tue Jan 18, 2005 9:35 am
Subject: standards

Well we had a great meeting last week with Carrie and Tosci and those present decided that what we really needed to do was to not support the document at all. Fight it on the basis of no authority to adopt anything but standards, have a speaker from MEAC or something to speak to standards. also use the argument that no other provider ie CNMs have regulations, it is a community based and individual thing etc...........

Does anyone want to go up to Davis to meet with Carrie to help her draft comments from CAM? I am going to go up there on Friday or Sunday. I prefer Friday. I imagine it will take half a day. Then i think that perhaps the lawyers from CAM and the medical board might meet the following week to discuss also. We need written comment from individual midwives.........Tosci will be sending us the talking points that we came up with at the meeting to help in writing letters to the medical board (needs to be done before Feb.7).

I personally feel so much better with this decision rather than accept those guidelines and try and edit them...........This means that there
won't be a unified effort at the medial board meeting because Faith will stand behind her document and of course Tanya will present her own document but still even with that discord, my stomach feels much more settled if we stick with the just say no attitude to this whole thing...........

So let me know if anyone can participate in the comment writing in Davis this week.........thanks........Diane

From: Diane Holzer <midwife@l... Date: Tue Jan 18, 2005 9:35 am
Well we had a great meeting last week with Carrie and Tosci and those present decided that what we really needed to do was to not support the document at all. Fight it on the basis of no authority to adopt anything but standards, have a speaker from MEAC or something to speak to standards. also use the argument that no other provider ie CNMs have regulations, it is a community based and individual thing etc...........

Hello Friends, Here is a copy of the letter I sent today to the board. Just thought I would pass it along to share what I said.
All the best, Lis

Susan Lancara,
Medical Board of California 20
1426 Howe Avenue, Suite 54
Sacramento, CA. 95825

January, 2005

Dear Medical Board Members,

Thank you for taking the time to read my letter in response to the proposed action of adopting standards of care for Licensed Midwives in California.

I will begin by saying that I am against adoption of the document entitled "Standards of Practice, Protocols, Guidelines and Minimum Practice Requirements for California Licensed Midwives" (any edition). It is stated in Section 26, section 2507(f) of Business and Professions Code that "the board shall adopt regulations defining the appropriate standard of care . ." but says nothing about adopting protocols, guidelines or minimum practice requirements.

I have enclosed copies of the Midwives Association of North America (MANA) Standards and Qualifications for the Art and Practice of Midwifery, the American College of Nurse-Midwives Standards for the Practice of Midwifery, and pages 1-4 of Section One from the California College of Midwives document which you are proposing be adopted.

These three documents are examples of true standards and any would be most acceptable for adoption. My preference is for the MANA standards as they are written by the national association representing direct-entry midwives, and Licensed Midwives are direct- entry midwives (as opposed to nursing trained)

This issue is a very important one to our community and impacts each one of us tremendously. Please take the time to fully examine all the options before making any decisions. If there is a need to have greater understanding of how a Licensed Midwife practices, it would be best to have one on the Board and I would be happy to do all I could to facilitate this.

Most Sincerely,
Alison (Lis) Worcester FNP, CPM, LM

From: Diane Holzer <midwife@l...>
Date: Fri Jan 21, 2005 10:59 pm
Subject: talking points

ok well i got the talking points from Tosci today, they are really in a very rough format........but i will pass them on.

We worked on the letter today, it is also still very rough but i will send it out to you all tomorrow for comment and input. I just want to get it out even if it is still rough to get everyones comments so that we can have time to edit etc........

Meanwhile Carrie is going to go over Faiths document to pick out the inconsistencies so we can cite them if need be..........i think a meeting with the lawyers is going to get planned for next week......this will be good.

ok so let me know what you think...missed you all at peer review...........

From: Diane Holzer <midwife@l...>
Date: Fri Jan 21, 2005 10:59 pm
Subject: talking points

k well i got the talking points from Tosci today, they are really in a very rough format........but i will pass them on.

We worked on the letter today, it is also still very rough but i will send it out to you all tomorrow for comment and input. I just want to get it out even if it is still rough to get everyones comments so that we can have time to edit etc........

Meanwhile Carrie is going to go over Faiths document to pick out the inconsistencies so we can cite them if need be..........i think a meeting with the lawyers is going to get planned for next week......this will be good.

ok so let me know what you think...missed you all at peer review...........

From: Diane Holzer <midwife@l...>
Date: Fri Jan 21, 2005 10:59 pm
Subject: talking points

From: Elizabeth Davis <edavis@b...>
Date: Sat Jan 22, 2005 10:35 am
Subject: Re: thanks Diane...some suggestions

Hi Diane,
I think that if we can flesh out these talking points a bit more, people might feel motivated to start writing their letters ASAP. So based on meeting with you all the other night, I’m starting out with one you didn’t mention, and what I remember of the rest:

nurse-midwives in CA have standards but no protocols in their regulations, and as our bill is a mirror of theirs, we should have the same

these are not national standards: the standards in Faith’s document are not national standards, but her own creation. We should uphold national standards as articulated through the Midwives Alliance of North America. MANA standards informed the development of the NARM exam and MEAC accreditation guidelines, which California recognizes by its use of the NARM exam for licensing midwives, and its requirement that educational programs be MEAC accredited.

medical board did not consider all options: focus on MANA standards

medical board stated at last board meeting that it would create a work
group to create standards, its "work group" was not representative of
California midwives: we want a work group of licensed midwives and MEAC approved program directors (my suggestion...)

leads to confusion between home and hospital based midwifery practices: as written, these protocols are not suitable for both, and as licensed midwives are entitled to work in both settings, and these protocols are not appropriate (the problem with this argument is that NO protocols are appropriate!)

Individual practice protocols: the NARM certification process requires that midwives uphold MANA standards and have on file individual practice protocols consistent with those standards, which may be audited . We suggest the same for California licensed midwives.

protocols change with practice setting and over time: the reason for keeping protocols out of regulations is that they change according to scientific evidence. Protocols that seem prudent now could prove inappropriate or even dangerous with new evidence. It is essential that protocols be regularly and frequently updated, a process which placing them in state regulation does not allow.

many inconsistencies in this document: speaks for itself

From:

"starA4" <stara4@y...>
Date: Sat Jan 22, 2005 7:30 pm
Subject: standards, once again

Hello Everyone, Here is the website for the American Academy of Nurse Practitioners. If you go to this page and click on Standards of Practice you will see what that profession has written. They are in the same style as the MANA and ACNM standards. THIS is the way all standards are written that I have had experience with.

Also, please note that Renee Anker and her CALM organization is supporting Faith's document and she has a relationship with the MBC too.

Let me know if you have trouble reaching the right info at the AANP site.

www.aanp.org/Practice+Policy+and+Legislation/Practice/Position+Statem
ents+and+Papers/Position+Statements+and+Papers.asp

All the best, Lis
p.s. this issue is so important I have thinking about flying to LA for the day of the meeting.

From: Diane Holzer <midwife@l...>
Date: Sat Jan 22, 2005 9:58 pm
Subject: text in email

i forgot that i can't send an attached file, i sent one to Maria Elena to send out but i will send within the email too so you can get it sooner in case Maria elena doesn't check her email tomorrow...so formatting may come thru wierd..............diane

===============================================================
DRAFT, DRAFT, DRAFT, DRAFT, DRAFT, DRAFT, DRAFT

California Medical Board
1426 Howe St.
Sacramento, CA

January 21, 2005

Re: Proposed regulations regarding standard of practice for midwifery

To Whom It May Concern:

The California Association of Midwives supports the adoption of Standards of Care for midwifery by the Medical Board, and we applaud the decision to define midwifery care as a distinct profession from medicine. However, after careful review and consideration of the proposed regulation by the midwives of California, we have found significant problems with the document written by the California College of Midwives.

The Medical Board of California has been directed by SB 1950 to adopt standards of care for midwifery practice. The proposed document goes far beyond standards of care to include protocols and practice guidelines. Protocols and practice guidelines should be developed individually by each midwifery practice based on the level of experience of the midwife, location and the availability and quality of medical and emergency care and consultation. For example an urban midwife may practice differently than a rural midwife and a newly licensed midwife will have different skill sets than a midwife of many years. Tosci will insert and example here……

We believe that there is a significant difference between standards, protocols and guidelines of practice. Enclosed is a letter from the attorney for the Midwifery and Education Accreditation Council (Dept. of Education approved), which gives definition to the terms standards of care, protocols and guidelines of practice. The North American Registry of Midwives (NARM) certification process requires that midwives uphold the standards of the Midwives Alliance of North America (MANA) and have on file individual practice protocols consistent with those standards, which may be audited. We suggest the same for California licensed midwives.

Protocols change with practice, setting and over time. The reason for keeping protocols out of regulations is that they change according to scientific evidence. Protocols that seem prudent now could prove inappropriate or even dangerous with new evidence. It is essential that protocols be regularly and frequently updated, a process which placing them in state regulation does not allow.

Furthermore, no other comparable health care practitioners such as Certified Nurse Midwives, Physician Assistants, or Nurse Practitioners have protocols and guidelines of practice within their statute or regulation. Once again these practitioners are given the mandate by the state to create practice specific guidelines depending on given situation.
The licensed Midwifery Practice act was created to mirror the Practice Act for Nurse Midwives and it should also be the same in this regard.

The Medical Board meeting of July 29 made a decision that they would create a task force to investigate adopting standards of care for Licensed Midwives. At this time the California Association of midwives specifically stated their desire to be included in this task force and the president of CAM was the identified contact. The president was not contacted about the meeting and when she found out about the meeting two days before the meeting occurred and asked to be included, she was told specifically that she would not be included. When a diverse group of midwives are involved in the decision making process the end product will be much more satisfactory. The proposed document was written by one midwife as opposed to a representation of Licensed midwives in California.

A good example of a collaborative effort occurred at the end of the last medical board meeting when a group of leading midwives present, 2 attorneys and a
representative from Senator Figueroa’s office met and drafted 1379.20 Sub Section B regarding Right to Refusal. As discussion ensued throughout the state, no midwife has been found to have objection to this sub-section. This underscores the need for a midwifery board with true representation of midwives on the decision making body.

The California Association of Midwives (CAM) has adopted the Standards of Care of the Midwives Alliance of North America. Most health professions such as The American College of Obstetricians and Gynecologists, the American College of Nurse Midwives, and the Midwives Alliance of North America have national standards of care that are then adopted by local regions or chapters. CAM has adopted the MANA standards of Care and
suggests that this is the appropriate standard for the Medical Board to adopt for California midwives. The MANA standards informed the development of the NARM exam and MEAC accreditation guidelines, which California recognizes by its use of the NARM exam for licensing midwives, and its requirement that educational programs be MEAC accredited.

The Licensed Midwifery Practice Act authorizes licensed midwives to practice in hospital, home and birth center practice. The proposed document by the California College of Midwives only covers home birth practices and ignores hospital based practice and potentially limits midwives who choose to work in that setting. This regulation would be confusing to potential hospital employers or physicians who wish to utilize midwifery services within a hospital-based practice.

The proposed document under review not only includes protocols and guidelines which go beyond what is necessary but there are also many inconsistencies in language and therefore it does not meet the clarity requirement in government code Section 11349C. For Example…..Carrie to insert a few examples….two definitions of emergency transport….etc…

In summary, after polling the membership of CAM and many discussions in each region regarding the proposed document, CAM finds that it cannot support this regulation as currently written. CAM believes that the Medical Board has the authority to adopt only standards of care for midwifery as opposed to protocols and guidelines of practice. No other midlevel practitioner requires guidelines of practice and protocols written into statute or regulation. The reason is that it is much too cumbersome to change regulations to reflect best scientific evidence. Protocols need to be practice specific. CAM would readily support the adoption of the National Standards of Care for Midwifery developed by the Midwives Alliance of North America, which is the national professional midwifery organization. CAM also believes that the inclusion of representatives from
CAM in any process that involves the adoption or creating of documents orregulations regarding midwifery practice is absolutely crucial.

We thank you for your work on this issue and look forward to working together to create regulations reflective of the standards of the majority of California licensed midwives.

Sincerely, I assume Carrie will be signing this document?

From: Elizabeth Davis <edavis@b...>
Date: Mon Jan 24, 2005 9:20 pm
Subject: Re: [camregion3] Re: Elizabeth's revisions/response

Hi Leah,
The reason I put the paragraph you mentioned first is that it explains why 1) Faith’s document got as far as it did with the Medical Board, and 2) why we are relatively late in protesting it. When it comes later, it just feels like tacked-on whining, to me at least. I think that this way, the letter has a logical progression— the paragraph just seemed dangling later on— but maybe you can figure out a way to make it make sense in the original position.

I am willing to meet Thursday after 2, in Marin if possible— unless Diane feels she can pull together a final draft that we might agree upon.
Love,
Elizabeth
======================================================

From: JoanWGreen@a...
Date: Sun Jan 23, 2005 9:55 am
Subject: Re: [camregion3] Re: revisions (with attachment!)

Diane and Elizabeth,

Thank you both, and Carrie and Tosi for all your work on this letter. I feel like this is such an important issue and feel that with these points I can write a letter to the Medical Board in the next few days. And I also, will speak to Susan Hodges to encourage her to write from the Cfm perspective.
Thanks, joan

From: sarah ridge <truebeautyiseverywhere@y...>
Date: Sun Jan 23, 2005 10:18 pm
Subject: Re: [camregion3] Fwd: Region 3's Update to the Standards issue.

want to thank everyone who has worked so hard on this and I appreciate your work so much as a student midwife on her way to getting her LM. I think you all are fabulous. I promise to do my part as I learn more.
Thank you!!!
Sarah Ridge
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From: Ronnie Falcao <ronnie@g...>
Date: Mon Jan 24, 2005 1:20 am
Subject: Re: My input on Letter writing campaign for LMs

At 02:44 PM 1/23/2005, Carrie wrote:
>>>I am sorry you were not included in this process. I am not sure where the breakdown was but I am checking it out. What region are you in? Did you get the packet I sent to all LMs in Sept. about this issue?

I am in Region 3, in the South Peninsula Peer Review group with about 15 other midwives, none of whom seems to be on your mailing list.

I cannot remember receiving a packet from CAM in Sept., but I do regularly receive mailings from CAM and I read and attend to them, so I assume that I read through the packet and acted accordingly.

>>>In terms of the document from the Calif College of Midwives, many CAM groups have been meeting around the state since Nov to critque this document and decide if we can live with it. Some of the main concerns are as follows:

One of my concerns is that if you've just been meeting since Nov., I'm wondering how you can understand the scope of issues that go back to before 1993.

>>>1. it only includes and directs to "domicillary" midwives, which excludes those practicing in a physicians office or hospital. It also doesn't include gyn care at all.

LMs working in a physician's office or hospital are guaranteed to be working under the direct supervision of a physician, right? They will be subject to the practice protocols of their supervising physician.

>>>2. much of the document is protocols not standards, and standards are all the MBC was instructed by the legislature to write. Protocols should be practice specific so they can change as evidence for safe care changes, while standards are usually created by the National organization of those to be addressed, ie ACNM created the ones for CNMs. Standards are a broad, overreaching document, designed to guide individuals in creating appropriate protocols and guidelines for their practice. CAM did adopt MANAs standards last Fall but not in time to present them to the MBC before the CCM document was proposed and adopted.

These are not protocols according to the protocols I've seen from other midwife groups, such as the New Mexico protocols.

>>>3. the work force at the MBC that decided on this was not representative of all California LMs, I was not included in the process as CAMs president, although I asked. The MBC announced at their July board mtg that they would create a representative work force to address this issue but in the end the only person outside the MBC that was invited was Faith. I have similar feelings to those you express about being unhappy with the CCM document when we (individuals and CAM) didn’t get on the boat sooner. However, as the meetings have progressed across the state it is clear, even from some who have consistently responded to Faith's document throughout the years (Tosi for one) that the current document goes far beyond what are considered Standards.

I don't know enough of the details of the history of this process to understand who would be invited and why. I do know that Faith has been going to Medical Board meetings for many years, and that there are usually very few other midwives there.

Have you been a regular at these meetings?

Is it possible that the Board felt that you hadn't displayed an historical interest in LM issues, and that since CAM is not the representative group for LMs, that you didn't have specific business with this issue?

Why isn't Faith participating in this discussion? I can't believe that you wouldn't have specifically solicited her involvement? Did she say why she declined to participate?

>>>4. CAM hired an attorney last Fall to represent us in this matter. His advice is to not accept these the way they stand. They are far too specific, no other organization has protocols (or even standards) incorporated in their statute or regulations and they may cause us severe trouble if we are sued in the future, for having gone beyond the scope of these "standards". He doesn't feel that having written refusal will allow us to provide any service a woman wants if she signs an informed refusal for it. If the service ends in a bad outcome the parents can still sue us and "you can't create a law that overrides another law"(our attorney). ie : if a woman at 43 weeks wants to stay at home, you get a written refusal, and then you end up with a stillbirth, you have still violated the law because this document doesn't allow us to stay home past 42 weeks.

Whoa! Do you mean that CAM has taken an adversarial stance against LMs? Why is CAM hiring an attorney to look into LM affairs when CAM has historically maintained its distance from these issues?

I know that there are at least a few midwives in CAM who have chosen not to become licensed because they don't support the licensure process. Is it possible that they are opposing these guidelines on the same basic principles? If so, how can they or their hired attorney be said to represent LM issues?

Your attorney has an interesting way of putting things. Obviously, the tax code is full of laws that technically contradict each other, i.e. your business income is taxable at such and such a percent UNLESS you used it to pay for business expenses. Technically, this would be one law "overriding" another. In actuality, they are taken as a body. Mind you, I'm not a lawyer, but I know they're very good at "spin".

And, of course, anybody can sue anybody, unless they've been declared a Vexatious Litigant, in which case they need the permission of the court in order to sue.

It's my understanding that civil suits are completely different from criminal suits, and that even MDs who are completely in line with their own laws still get sued.

Does your lawyer hold out a promise of some magic law that will keep LMs from ever being sued, or is this just a side issue?

>>>5.The paragraph that allows us to do breeches and twins was written, not by the MBC, but by a few leading midwives, CAMs attorney and the MBC attorney. It was written in about 45 minutes at the end of the midwifery task force meeting in Nov. This is what can happen when you involve representatives of all midwives in the discussion.

Wouldn't it be wonderful if they had gotten involved when this whole thing began . . . how many years ago?

I can't wait another 15 years for guidelines that all midwives love and that the MBC will approve, and I'm not sure that even 15 years is enough time to make this a reality.

Do you believe that the momentum of the past few months will carry through for another 15 years, and that all the people who have energy now for writing letters and soliciting letters from their clients will be doing this for the next 15 years?

Having heard tales of the MBC from the midwives I know who DO attend MBC meetings regularly, I know that the MBC can be capricious and that they are not always completely sympathetic to LM issues. My feeling is that we should strike while the iron is hot and get these guidelines approved.

Then, with all the good energy that camregion3 seems to have, you can work to improve them. If you're confident that you would be able to get ideal guidelines approved, starting from ground zero, then it makes sense to me that you would be confident about being able to get the proposed
guidelines updated.

>>>It is extremely important that we, midwives and consumers, cleve together regarding this important regulation for LMs. CAM, MANA, MEAC, NARM, individual midwifery schools, consumer groups and individuals are all writing letters regarding this regulation. We must be shown to have a united front or we will be seen to be disorganized and dunable to even decide amongst ourselves what are appropriate standards for the practice of midwifery in California.

Well, quite frankly, we ARE disorganized. The situation as I see it is that a single Peer Review group is being persuaded by midwives who are not, themselves, LMs, to formulate their own policy and present it to the MBC as a consensus from LMs.

And all this without attempting to contact LMs through the avenues that sprang up spontaneously because CAM refused to take a leadership role with LMs, even though someone in your group knew that such lists existed.

And it is already too late for the united front approach. My clients have already sent their letters, as have I.

>>>The CCM document is acknowledged by all I've talked to have very encouraging language. What I would like to stress is that there is a huge difference between "Standards" and "Protocols". What we need to stick to with this regulation is a document that is purely "standards" and not "protocols". Protocols, in use, should be practice specific. they should be evidence based and as such easy to change when the evidence changes. Incorporating them into regulations will make timely change extremely difficult. Another thing to consider is that the protocols for transport will be very different for a practice that is far from a hospital and snowed in during the winter, as opposed to a practice that is in an urban center with multiple hospitals within 20 minutes. This is just an example but there are many others in the CCM document.

Let me ask you straight, here, Carrie. How many times has Faith asked you to review the guidelines that she was editing? Did you offer feedback? Was it incorporated?

>>>For an example of Standards visit ACNMs site and view theirs.

For anyone else who had trouble finding these, they're at:

http://www.acnm.org/prof/display.cfm?id=138

These are significantly different from our proposed guidelines, but they are meaningless in the State of California, which requires that CNMs work under the supervision of a physician.

If the MBC is going to be OK with having LMs work without supervision, it makes sense that they would want tighter guidelines than the ACNM provides.

>>>I greatly encourage feedback and comments and strongly ask that we all pull together on this. As a body we have much more clout than we do as multiple organizations and individuals.>Blessings >Carrie >CAM President

I have not heard any reassurances that anybody involved in putting together the alternative approach has the MBC experience necessary to understand the issues and to politic anything into reality.

Why should I pass up an opportunity to support guidelines that I can live with for pie-in-the-sky, which is what you seem to be offering?

- Ronnie

Ronnie Falcao, LM, MS - homebirth midwife, labor coach
Mountain View, California, near San Jose, south of San Francisco, CA, USA

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From: Ronnie Falcao <ronnie@g...>
Date: Mon Jan 24, 2005 1:36 am
Subject: How do we submit opinions to the CAM board?

I'm glad to hear that the CAM board will likely serve as a conduit to get position papers out to those of the CAM membership who have been invited to join their local e-groups.

How do I submit a position paper?

I'm sure I'm not the only one with this question, which is why I'm posting it to the entire list.

Thank you,
Ronnie

From: Leah Redwood <leahmidwife@m...>
Date: Mon Jan 24, 2005 5:36 am
Subject: Re: [camregion3] Re: My input on Letter writing campaign for LMs

Ronnie -

I feel a need to provide some background that seems to be missing here. Some of the midwives involved in this discussion are the midwives who wrote the licensing legislation and got it passed in the first place, and were involved in the many previous attempts to get legislation passed. This is not a group that is new to midwifery politics in California.

I'm not sure why you believe that CAM decided not to be involved with LM issues at all, I do remember that CAM took a stance at one point of not being exclusively for LMs, but to represent all midwives in California. However, CAM has continued to be involved in LM legislation issues and representatives have attended Med. Board meetings regularly. Not as consistently as Faith, but for a time until very recently Faith was the CAM representative to the Med. Board. She resigned her position just after the Med. Board meeting last summer in Sacramento, which many of us from the region attended.

As far as involving Faith in our discussions, we had a meeting with her at my house a few weeks ago to discuss this and out of that she and I spent many hours creating the document that is now on her website with our draft of possible edits. Through this process we have tried to come to agreement amongst all midwives about how to approach this and get the best possible long term outcome for all midwives in this state.

One really important thing to be aware of that Faith has specifically brought to this discussion herself is that these standards will not be in exchange for physician supervision. It is a completely separate issue. And if these standards are accepted as they are and incorporated into our law, it will take legislation to change them, which can take years.

Our law is technically exactly the same as the CNM law and they do not have detailed guidelines and protocols incorporated in their law. Each CNM determines her protocols and guidelines with her individual practice group, and they are a working document that is changed regularly. We need to be able to have individualized protocols consistent with our practice setting and experience.

I believe our goal should be to have national standards, not an entirely different set of criteria state by state. That is why I support the MANA Standards. They were created by a body of midwives from all over the country and they are consistent with the standards for other healthcare professionals. If the Med. Board needs to have better understanding of what midwives do they should have an LM on the Med. Board, not incorporate what Faith has identified as a teaching document, that she never expected to be adopted as the standards, into the law for all LMs.

We clearly need to have greater connection amongst all the midwives in California and this seems like a crucial time to try and make that happen. Yes we are disorganized but now is a perfect time to remedy that. Time is short, but if we all have the best for licensed midwives at heart I believe we can come to agreement.

We are having a meeting for CAM Region 3 in San Francisco on Tues. Feb 1st at 7:00pm. We have in the past tried to incorporate South Bay midwives into our regular meetings, but it has never been very successful. If we had a meeting up here very few S. Bay midwives would come and if the meeting was in the S. Bay very few midwives from the other parts of the region would come. It would be great if you could attend this meeting in Feb. and maybe we could organize another meeting in the S. Bay sometime soon. A notice for the meeting with location info will go out on this list beforehand.

Leah Redwood, LM, CPM
Sacred Body Midwifery
San Francisco, CA
(415)824-2461

From: Leah Redwood <leahmidwife@m...>
Date: Mon Jan 24, 2005 11:00 am
Subject: Re: Elizabeth's revisions (with attachment!)

I'm not sure how this is going to work, but I like starting the letter with the paragraph that Diane's original letter started with and making the not inviting Carrie to the task force meeting a smaller point later in the letter - it doesn't feel like the main point to me and also not a good place to start. I don't have time to do my own version of the letter right now and it doesn't seem like that would be helpful – seems like we may need to meet as a working group to get a final version together. And soon. Maybe we could meet sometime this week (Wed afternoon, Thurs until 11:00am or after 2:00pm or anytime during the
day on Sunday work for me). Anyone else available?

Love, Leah
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From:

Mariaelena Quale <eastbaydoula@g...>
Date: Mon Jan 24, 2005 9:04 pm
Subject: Fwd: please post

I am forwarding this message, per Carrie's request.
Mariaelena

---------- Forwarded message ----------
From: Carrie <carrielm@s...>
Date: Mon, 24 Jan 2005 8:18pm
Subject: please post
To: Mariaelena Quale <eastbaydoula@g...>, Diane West
<diane_west@h...>

this cam back, could you please post
CS

Let me begin by saying that in addition to my comments below, I am working with our attorney on creating a document for comments from CAM that includes the major likes as well as the major dislikes from CAM members. It is clear we do not have consensus on this but it will not help us to be angry, resentful or otherwise in opposition to working on this together. As CAMs president I am working to find solutions that are agreeable to all in addition to being something the MBC might accept.
CS

Carrie’s most reply (in red) to Ronnie’s comments on earlier email from Carrie:

Original posted at 02:44 PM 1/23/2005:
Carrie/original text : I am sorry you were not included in this process. I am not sure where the breakdown was but I am checking it out. What region are you in? Did you get the packet I sent to all LMs in Sept. about this issue?

Ronnie: I am in Region 3, in the South Peninsula Peer Review group with about 15 other midwives, none of whom seems to be on your mailing list. Surely someone in your peer group, esp someone in CALM knew this was going on. Also I sent a packet to all LMs in Sept. and I'm pretty sure at least one of the 15 people you meet with got it.

I cannot remember receiving a packet from CAM in Sept., but I do regularly receive mailings from CAM and I read and attend to them, so I assume that I read through the packet and acted accordingly. In terms of the document from the Calif College of Midwives, many CAM groups have been meeting around the state since Nov to critque this document and decide if we can live with it. Some of the main concerns
are as follows:

One of my concerns is that if you've just been meeting since Nov., I'm wondering how you can understand the scope of issues that go back to before 1993.

Carrie: No one knew until Oct, even Faith, that this would be the document the MBC would adopt for all midwives in CA. Many people over the last few years have gotten Faiths document and have either commented on it or not. It isn’t fair to call this consensus since even the writer didn’t realize its end purpose. CAM has been discussing what to favor in terms of Standards since the MBC was instructed by the legislature to adopt them. CAM DID adopt the MANA standards at our BOD mtg in November 2004. There was not enough time between finding out that this is what the MBC would adopt and our BOD mtg to do anything else

Carrie/original text 1. it only includes and directs to "domicillary" midwives, which excludes those practicing in a physicians office or hospital. It also doesn't include gyn care at all.

Ronnie: LMs working in a physician's office or hospital are guaranteed to be working under the direct supervision of a physician, right? They will be subject to the practice protocols of their supervising physician. Not the way this is written. The MBC believes it is adopting standards for all midwives as was directed by the legislature

Carrie/original text 2. much of the document is protocols not standards, and standards are all the MBC was instructed by the legislature to write. Protocols should be practice specific so they can change as evidence for safe care changes, while standards are usually created by the National organization of those to be addressed, ie ACNM created the ones for CNMs. Standards are a broad, overreaching document, designed to guide individuals in creating appropriate protocols and guidelines for their practice. CAM did adopt MANAs standards last Fall but not in time to present them to the MBC before the CCM document was proposed and adopted.

These are not protocols according to the protocols I've seen from other midwife groups, such as the New Mexico protocols. The title of the CCM document contains the wording "protocols and guidelines"

Section 1-I Practice protocols
Page 23 and 24 are all protocols
I could go on there are many examples

Carrie/original text / 3. the work force at the MBC that decided on this was not representative of all Calif LMs, I was not included in the process as CAMs president, although I asked. The MBC announced at their July board mtg that they would create a representative work force to address this issue but in the end the only person outside the MBC that was invited was Faith. I have similar feelings to those you express about being unhappy with the CCM document when we (individuals and CAM) didnt get on the boat sooner. However, as the meetings have progressed across the state it is clear, even from some who have consistently responded to Faith's document throughout the years (Tosi for one) that the current document goes far beyond what are considered Standards.

Ronnie: I don't know enough of the details of the history of this process to understand who would be invited and why. I do know that Faith has been going to Medical Board meetings for many years, and that there are usually very few other midwives there. Have you been a regular at these meetings? I have, until recently, only attended sporadically.
CAM has now asked and I have agreed to take Faiths place as MBC liason, which I began doing last summer

Ronnie: Is it possible that the Board felt that you hadn't displayed an historical interest in LM issues, and that since CAM is not the representative group for LMs, that you didn't have specific business with this issue?

Carrie: I think it is wholly possible that you are correct about whether they knew me. As far as the CCM being the representative body for LMs neither Faith or CAM has a majority of LMs in their membership. I do know that of the approx 150 LMs holding current CA licenses there are 35 in the CCM and 53 in CAM. There is admitted overlap between the orgs. So no group can claim they are THE representative group and neither has.

Ronnie: Why isn't Faith participating in this discussion? I can't believe that you wouldn't have specifically solicited her involvement? Did she say why she declined to participate?

Carrie: We did and she has, boisterly.

Carrie/original text 4. CAM hired an attorney last Fall to represent us in this matter. His advice is to not accept these the way they stand. They are far too specific, no other organization has protocols (or even standards) incorporated in their statute or regulations and they may cause us severe trouble if we are sued in the future, for having gone beyond the scope of these "standards". He doesn't feel that having written refusal will allow us to provide any service a woman wants if she signs an informed refusal for it. If the service ends in a bad outcome the parents can still sue us and "you can't create a law that overrides another law"(our attorney). ie : if a woman at 43 weeks wants to stay at home, you get a written refusal, and then you end up with a stillbirth, you have still violated the law because this
document doesn't allow us to stay home past 42 weeks.

Ronnie: Whoa! Do you mean that CAM has taken an adversarial stance against
LMs? Why is CAM hiring an attorney to look into LM affairs when CAM
has historically maintained its distance from these issues?

Carrie: CAM has not "Historically" maintained a distance from LM issues. CAM consistently has supported LMs, workiing on licensure, regulations and many other matters that concern LMs. Perhaps you are thinking of CAMs decision 5 years or more ago to support and represent all California midwives, regardless of their legal status. This has not changed.

Faith was asked and she accepted to be the CAM liason to the MBC so that through her report we could keep in touch with what we needed to address. She publically gave up that job, in front of the MBC, in July of last year and I took it on.

I know that there are at least a few midwives in CAM who have chosen not to become licensed because they don't support the licensure process. Is it possible that they are opposing these guidelines on the same basic principles? If so, how can they or their hired attorney be said to represent LM issues? An attorney is an attorney is an attorney.

CAM, all 10 regions, voted to hire a specific attorney, Tim Chambers. Tim is as well versed in midwifery as we could hope. He has had 2 midwife (LM) attended home births and has been the attornry for a midwifery birth center in Marin. Tim was hired, by CAM, specifically to represent the cause of licensed midwives on this issue.

Possibly because CAM members saw that this would impact not only LMs but DEMs etc. It kind of sounds like you think there was a conspiracy between non-LM CAM members to dislodge this regulation. I'm pretty sure those who might be involved dont have the ability to get it together so quick. Besides, the proposal to hire an attorney was created without prior knowledge of the route the MBC was going to take.

Ronnie: Your attorney has an interesting way of putting things. Obviously, the tax code is full of laws that technically contradict each other, i.e. your business income is taxable at such and such a percent UNLESS you used it to pay for business expenses. Technically, this would be one law "overriding" another. In actuality, they are taken as a body. Mind you, I'm not a lawyer, but I know they're very good at "spin". And, of course, anybody can sue anybody, unless they've been declared a Vexatious Litigant, in which case they need the permission of the court in order to sue. It's my understanding that civil suits are completely different from criminal suits, and that even MDs who are completely in line with their own laws still get sued.

Does your lawyer hold out a promise of some magic law that will keep LMs from ever being sued, or is this just a side issue?

Carrie: NO, but the MBC attorney is in agreement with what our attorney said on the subject.

Carrie/original text 5. The paragraph that allows us to do breeches and twins was written, not by the MBC, but by a few leading midwives, CAMs attorney and the MBC attorney. It was written in about 45 minutes at the end of the midwifery task force meeting in Nov. This is what can happen when you involve representatives of all midwives in the discussion. Wouldn't it
be wonderful if they had gotten involved when this whole thing began . .

Carrie: These were the MW who have been involved all along. You make it sound as if there have been years and years to write and go over this document. The legislature was only given notice 3 years ago that they had to come up with this. Faith has done a good job of keeping CAM informed, in that she told us we needed to create standards and then when the MBC had something in writing she thought, and so did CAM, that they were acceptable.

It wasnt until the MBC mtg in Nov of 03 that we knew they we're going to pass theoriginal. In July last year we were given the message to adopt or else and that the MBC would create a "work group" to help in their creation. They indicated that would take place in the Fall and would consist of several individuals from the midwifery community. CAM had every reason to expect that I would be involved. In fact, they refused to allow the participation of anyone outside the MBC but Faith, even though I pleaded to be allowed to present. We didnt know until the end of that mtg, Oct 8, 2004, that it was the CCM document they would adopt.
Just for the record; Faith, Karen E., myself, Tonya Brooks, Diane Holtzer and our attn and their attn. were the ones present when paragraph b was written.

Ronnie: I can't wait another 15 years for guidelines that all midwives love and that the MBC will approve, and I'm not sure that even 15 years is enough time to make this a reality. Do you believe that the momentum of the past few months will carry through for another 15 years, and that all the people who have energy now for writing letters and soliciting letters from their clients will be doing this for the next 15 years? Having heard tales of the MBC from the midwives I know who DO attend MBC meetings regularly, I know that the MBC can be capricious and that they are not always completely sympathetic to LM issues. My feeling is that we should strike while the iron is hot and
get these guidelines approved. Then, with all the good energy that camregion3 seems to have, you can work to improve them. If you're confident that you would be able to get ideal guidelines approved, starting from ground zero, then it makes sense to me that you would be confident about being able to get the proposed guidelines updated.

Carrie: This is a good point, but I don’t think we are going to go in that direction.

Carrie/original text: It is extremely important that we, midwives and consumers, cleve
together regarding this important regulation for LMs. CAM, MANA, MEAC, NARM, individual midwifery schools, consumer groups and individuals are all writing letters regarding this regulation. We must be shown to have a united front or we will be seen to be disorganized and dunable to even decide amongst ourselves what are appropriate standards for the practice of midwifery in California.

Ronnie: Well, quite frankly, we ARE disorganized. The situation as I see it is that a single Peer Review group is being persuaded by midwives who are not, themselves, LMs, to formulate their own policy and present it to the MBC as a consensus from LMs.

Carrie: I have solicitated input from all regions in CAM. All but one region has weighed in. It seems to be consensus that the "Standards" per se are adoptable. It is also true that there are varying degrees of dissent among midwives regarding the rest of it. Some have very strong concerns and others are mild. What is clear from the comments I have received is that there is no consensus on this issue.

Ronnie: And all this without attempting to contact LMs through the avenues that sprang up spontaneously because CAM refused to take a leadership role with LMs, even though someone in your group knew that such lists existed.

Carrie: I, personally, have made every attempt possible to contact everyone. The mailing I did in Sept included the mailing list from CALM as well as CAMs and the MBCs. I gave explicit instructions to al regional reps to contact and engage with all voting CAM members in their regions on this issue.

And it is already too late for the united front approach. My clients
have already sent their letters, as have I.

Carrie: I find it a shame that you didn’t think to make contact before you decided that you would not be represented. I also think you should look again at the CCM document and see if you cant at least see what others are concerned about.

Ronnie: The CCM document is acknowledged by all I've talked to have very encouraging language.

Carrie/original text: What I would like to stress is that there is a huge difference between "Standards" and "Protocols". What we need to stick to with this regulation is a document that is purely "standards" and not "protocols". Protocols, in use, should be practice specific. They should be evidence based and as such easy to change when the evidence changes. Incorporating them into regulations will make timely change extremely difficult. Another thing to consider I that the protocols for transport will be very different for a practice that is far from a hospital and snowed in during the winter, as opposed to a practice that is in an urban center with multiple hospitals within 20 minutes. This is just an example but there are many others in the CCM document.

Ronnie: Let me ask you straight, here, Carrie. How many times has Faith asked you to review the guidelines that she was editing? Did you offer feedback? Was it incorporated?

Carrie: I never reviewed them previous to this current need, it wasn’t necessary until now. As I have already said it was a moot point when all she was doing with them was giving them to the MBC to read so they might know if they were prosecuting us appropriately. The MBC had never even seemed interested in them until the last 15 minutes of the mtg I was not at, in OCT. No one, even Faith, had even the vaguest idea that the MBC would propose them much less adopt them. Did I fail in this, in hind site yes.. I wish I had been ore proactive. The fact is I relied on the CAM appointee to the
MBC to keep me informed, Faith.

Ronnie: For an example of Standards visit ACNMs site and view theirs. For anyone else who had trouble finding these, they're at: http://www.acnm.org/prof/display.cfm?id=138

These are significantly different from our proposed guidelines, but they are meaningless in the State of California, which requires that CNMs work under the supervision of a physician. so does our law, they are just an example anyway as to the difference between what Faith compiled and true "Standards"

If the MBC is going to be OK with having LMs work without supervision, it makes sense that they would want tighter guidelines than the ACNM provides.

Carrie: They aren’t OK with having us work without supervision. They have laid that aside for the present as unworkable while they await the AG opinion regarding what they wanted to adopt to cure the supervision issue. Don't think for a minute that if these are adopted the MBC will forget about the supervision issue, they won’t and can’t.

I greatly encourage feedback and comments and strongly ask that we all pull together on this. As a body we have much more clout than we do as multiple organizations and individuals. Blessings Carrie CAM President

Ronnie: I have not heard any reassurances that anybody involved in putting together the alternative approach has the MBC experience necessary to understand the issues and to politic anything into reality. Why should I pass up an opportunity to support guidelines
that I can live with for pie-in-the-sky, which is what you seem to be offering?

Carrie: It is fine for you to individually do whatever you want. The problem with many people submitting many responses, is that midwives once again look like a bunch of renegades who cant even agree amongst themselves.

I hope that you and others will consider giving input while this is on the table, which might be for many more months.
Thanks, Carrie

From: Elizabeth Davis <edavis@b...>
Date: Mon Jan 24, 2005 9:20 pm
Subject: Re: [camregion3] Re: Elizabeth's revisions/response

From: Diane Holzer <midwife@l...>
Date: Mon Jan 24, 2005 10:46 pm
Subject: Re: [camregion3] Re: Elizabeth's revisions (with attachment!)

I agree with you Leah, we should start out by thanking them and I also think that the issue of not inviting Carrie is not the main point and should be later in the letter...........thurs could work for me i think.........

From:

"mariaelena quale" <eastbaydoula@g...>
Date: Tue Jan 25, 2005 11:34 am
Subject: Re: Elizabeth's revisions/response

I seem to agree with Elizabeth - stating the fact that we should always be represented (and invited) to the board meetings in the first paragraph underscores this basic and fundamental need. I think it also segueways to the reason why we as CAM did not have a document or a prepared statement of our wishes and intentions during that meeting. It shows that we were not being wishy washy or lazy but that we were in fact not represented, since Carrie was not invited.

Mariaelena

From: Ronnie Falcao <ronnie@g...>
Date: Tue Jan 25, 2005 10:46 pm
Subject: C.A.L.M.'s support for Proposed Standards

Licensed Midwives wishing to make an informed choice about their vote regarding the proposed Standards of Practice may wish to take a look at: http://www.calmidwifery.org/

- Ronnie
******************************************************
Background information:

There are 3 groups that have been focused on LM politics:

Californians Advocating Licensed Midwifery:
http://www.calmidwifery.org/
This group was organized by LMs to advocate for positive legislation for LMs. Renee Anker is a regular at the Medical Board meetings.

California Citizens for Health Freedom:
http://citizenshealth.org/
Frank Cuny has a lot of experience with California law pertaining to alternative health care practitioners. He has also accompanied midwives to their interviews with Medical Board investigators, when requested. Frank is also a regular at the Medical Board meetings.

California College of Domiciliary Midwives:
http://www.collegeofmidwives.org/college_of_midiwves01/CalCollegeindex01.htm
Representing the Legal & Legislative Issues of California Licensed Midwives. Faith Gibson is a regular at the Medical Board meetings.

All 3 of these groups support the proposed Standards.

I know there are midwives who feel ethically obligated to present their clients with full information about the discussion about the proposed Standards. You'll definitely want to include the 3 groups listed above.

Ronnie Falcao, LM, MS - homebirth midwife, labor coach
Mountain View, California, near San Jose, south of San Francisco, CA, USA
===============================================================

From: Ronnie Falcao <ronnie@g...>
Date: Wed Jan 26, 2005 4:46 am
Subject: Re: Carrie's resp to Ronnie

At 07:43 PM 1/24/2005, Carrie wrote:

>>If you're confident that you would be able to get ideal guidelines approved, starting from ground zero, then it makes sense to me that you would be confident about being able to get the proposed guidelines updated. This is a good point, but I don’t think we are going to go in that direction.

Why not?

Why not support the proposed guidelines or remain neutral?

This would seem to satisfy everyone:

Those who believe this is a rare and possibly unique opportunity would feel relieved that it wasn't squandered.

Those who believe that the Medical Board is open to whatever CAM proposes would feel confident that any shortcomings in the current document would be corrected in the future.

Everyone goes home happy.

- Ronnie

P.S. I responded to the rest of Carrie's long response to me
privately, at length. If anyone would like to know what I said
about a particular issue, please don't hesitate to ask.

I have been trucking your number around with me for weeks now, hoping to find time to give you a call back. Thank you so much for your call on Hugh's first birthday - it was such a special day to remember and think back to his entry into the world. What an experience. I don't know how it would have gone without your coaching session on how to cope and what to do. Your techniques really carried us through. We're hoping to have another one this year.

What do you need? Is it to late for me to do anything? I'd be happy to help you with whatever you're working on. Incidentally, I still have your Babycatcher book. Truly a gem - I appreciate the loan, and I intend to get it back to you.

My home number is 360-736-9933