January 29, 2009

Midwives Seek Inclusion In Health Care Reform

Supporters of home births are challenging politicians and the medical community to allow midwives to play a greater role in maternity care, and to scale back laws that limit their practice.

Some 25 states have already taken such steps, and pending bills to broaden midwife care have received widespread support in many other states as well.

An organization called the Big Push for Midwives marked President Barack Obama's inauguration with an aggressive e-mail campaign, urging the new administration to ensure that midwives who specialize in home births are included in negotiations on federal health care reform.

"We're at a tipping point now," Katherine Prown, the Big Push campaign manager, told the Associated Press.

"Home births are still only a small part of the total, but it's poised for growth."

The campaign seeks to highlight that in this time of economic crisis and uncertainty, home births can be a satisfying, safe and cost-saving option for many women.

However, the efforts are falling under fierce opposition from the American College of Obstetricians and Gynecologists and the American Medical Association (AMA).

"Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause celebre," reads the obstetricians' policy statement.

"Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby."

There were roughly 25,000 home births nationwide in 2006, most assisted with midwives, according to the latest federal data.  It's a modest number considering the nearly 4.3 million national births in 2006.

However, midwife-attended home births increased by 27 percent from 1996 to 2006, and advocates believe the numbers will continue to rise as more states update their laws to accommodate the practice, which supports say is at least as safe as hospital births for healthy women with low-risk pregnancies.

Prown said the state campaign generates strength through its diversity of participants.

"We're one of the few movements that's succeeded in bringing together pro-life and pro-choice activists, liberal feminists and Christian conservatives," she said.

"In every state we manage to recruit Republican and Democratic co-sponsors who normally would never be on the same bill together."

The 50 U.S. states are now evenly split on legal recognition of certified professional midwives (CPMs).   Half have procedures allowing CPMs, who lack nursing degrees but account for most midwife-assisted home births, to practice legally.  The other 25 states are without such laws, subjecting CPMs to prosecution for practicing medicine without a license.

However, the balance among the states could shift this year depending on the upcoming legislative decisions in states such as North Carolina, Idaho and Illinois.

In December, a North Carolina House study committee advised the legislature to develop licensing standards for CPMs, saying the current system does not meet the needs of women who opt for non-hospital births because of an "extremely limited supply" of obstetricians and nurse-midwives.

And in Idaho, advocates who previously failed to win legislative approval for a voluntary licensing bill have returned with a mandatory licensing bill.  State Representative Janice McGeachin  (R-Idaho Falls) says the changes persuaded the state boards of nursing and pharmacy to abandon their opposition. The Idaho Medical Association, which had opposed the earlier version, expressed some support for the new bill and is considering whether further changes might produce a version it could accept.

Advocates in Illinois have returned with an updated version of a licensing bill that fell short in 2007.  Representative Julie Hamos (D-Evanston) says its tougher  standards for CPMs prompted the Illinois Nurses Association to drop its opposition.  However, the Illinois State Medical Society remains opposed to the new bill.

"There are many in the legislature who feel a need to have this option - they need to be educated," society president Dr. Shastri Swaminathan told the Associated Press.

"We're in strong opposition to licensing midwives who don't have the medical training to provide safe home births."

Cost is a significant component of the debate.  For instance, a typical hospital birth often can cost between $8,000 and $10,000, or even more for C-section deliveries, which now account for 31 percent of all U.S. births.

But midwives' fees for home births are typically less than one-third this cost, since mothers usually decline epidural anesthesia or other medical interventions at home.

Insurance coverage is another significant factor.  While many insurers cover nurse-midwife care in hospitals, such coverage is less common for those who aren't nurses or work with home births.

Many doctors admit that the soaring costs of maternity care and the high rate of C-sections are problems.

"But the answer is not to have births at home," Dr. Erin Tracy, an obstetrician at Massachusetts General Hospital, told the Associated Press.

"We obviously support women's empowerment, but the No. 1 guiding principle has to be the health and safety of the mother and baby."

The national physicians' groups does support midwife-assisted births in hospitals and birthing centers, as long as midwives have completed nursing school or an equivalent postgraduate program.

While the American College of Nurse-Midwives, the group that represents these midwives, says it disagrees with the AMA in considering home births an acceptable option for pregnant women, it believes only nurse-midwives or others with equivalent training should be allowed to assist.

"We don't believe it's safe without being integrated into the full health care system," college president Melissa Avery told the AP.

The education standards supported by the college leaves out many of the approximately 1,400 certified professional midwives that acquire training through apprenticeships.  That would mean that midwives such as Jane Peterson, 56, of Iola, Wisconsin, who began her apprenticeship in 1980 and has attended more than 1,330 births since that time, would not be endorsed by the college.

Peterson said she works hard to build collaborative relationships with local physicians so that transfers to hospitals go smoothly should risks develop. She believes such relationships should be encouraged throughout the country, so women feel at ease opting for home births.

"People will tell you that you changed their lives," Peterson told the AP, referring to the rewarding nature of her job. 

"It's hard work - getting up on a cold winter night, going out one more time through the snow. What keeps you going is the recognition women feel - as though they are a different kind of mother when they've been able to give birth their way."

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