ALTERNATIVE DOCTOR, LLC
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ALTERNATIVE DOCTOR, LLC
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MIDWIFERY The history of Midwifery in the United States is filled with health care politics and conflicting interpretations of statistics and events. What is not in question is the fact that despite100 years of evidence showing the European model of midwifery care to be at least as safe as - and often safer than - the physician/hospital model for both pregnant women and their infants, there have been extreme efforts to eliminate the profession from the nation's health care choices. Although reports vary, it appears that between 1910 and 1935 the percentage of midwife-attended births in this country fell from around 35-40% to around 10%, and continued to fall over the next 20 years to a low of about 3% in the early 1950s. The struggle for control of birthing began in the late 1800s, when the American Association of Obstetricians and Gynecologists was formed (1888). Not all members opposed midwifery, but the goal of the group was certainly to declare childbirth a medical specialty requiring physician intervention and care. They were very successful. Although the Sheppard-Towner Maternity and Infancy Protection Act was passed in 1921, providing funds for the training and regulation of midwives (an important step toward improving and standardizing midwifery training), continued opposition from the American Medical Association and obstetricians resulted in the act's expiration by 1929, followed by 50 years of a significant struggle for the profession's very survival. As with many alternative health care approaches, renewed interest in midwifery began to build in the mid-to-late 1970s and has grown slowly but steadily since then. The population expansion of the last quarter century has been so significant that today’s percentage of midwife-attended births is still very low (less than 5%), but the number of such births has grown to around 200,000 annually. More important, a growing body of research has demonstrated that midwife-delivered care continues to be a safe, effective and highly cost-effective alternative. The World Health Organization, a staunch supporter of midwife-delivered care, has pointed out that midwives deliver over 70% of the babies born in Western Europe, with lower infant and maternal mortality, lower cesarean rates and lower overall costs. Such statistics have led the WHO to recommend out-of-hospital birth as the standard of care for normal birth. Estimates of the cost savings of implementing such a policy in the U.S. and making midwifery care widely available range between $13 billion and $20 billion a year. Even such incentives as these have unfortunately not yet really penetrated the American consciousness, in provider, payer or consumer communities. In the United States today, there are two recognized branches of midwifery: direct entry midwives and nurse-midwives. Both have established standards, accreditation of schools and excellent outcomes. However, nurse-midwives have a much closer relationship with hospital-based care and are much less likely to do home births; as nurses, they are governed by medical standards and guidelines. Direct-entry midwives do not practice medicine, as the law defines it, and the vast majority practice in the out-of-hospital setting. These differences have both historical and philosophical roots. Direct-entry midwives evolved from the ancient practice of having experienced older women assist younger women in the birth process. Over the centuries, a recognized profession emerged, with training by apprenticeship outside the context of medical or nursing schools. Herbal lore, hands-on clinical knowledge and home-based care of women (and children) by women were hallmarks of the midwifery tradition. Today’s direct-entry midwives have independent practices, acquire their education through a variety of means, and still are the primary providers of home birth services. Nurse-midwifery was brought to the United States from Great Britain in 1929 by Mary Breckinridge. A nurse herself, she had observed midwife-delivered maternity care in France and England and was very impressed with the quality of care and the excellent outcomes for mothers and infants. The first U.S. schools were founded in the 1930s,and the profession grew slowly but steadily. Today there are more than 40 standardized programs in the U.S. and 4-5,000 CNMs (Certified Nurse-Midwives), attending more than 150,000 births annually, primarily in hospitals. Both branches of midwifery see birth as a normal event in a woman’s life, but there are significant differences stemming from adherence to either the medical model or the midwifery model. The Midwives Alliance of North America has crafted the following definition:
The American College of Nurse Midwives offers the following perspective:
Studies of midwife-delivered care have shown decreased incidence of prematurity and low birth weight, decreased neonatal death rate, increased compliance with schedules for prenatal care, and 50% fewer cesarean sections. The U.S. has among the worst maternal and infant mortality and morbidity statistics in the Westernized world, and the highest rate of cesarean section. Although midwifery has survived and is beginning to thrive here, prejudice and misinformation still guide most people’s decisions about births. The United States still has a long way to go in undoing the harm that has been done to our nation’s women and infants through the suppression of midwifery and the medicalization of the birth process. Midwifery licensing does differ for direct-entry midwives and nurse-midwives, and the statutes regulating each branch also vary from state to state (although the variations are fewer for nurse-midwifery, which is regulated in all 50 states). The training of both branches, however, encompasses comprehensive management of prenatal, delivery and postnatal services for the healthy woman and well-baby care for the first two to six weeks of life. A comprehensive listing of the areas of competence one can expect of a Certified Professional Midwife can be found at http://web.archive.org/web/20010204015400/http://www.mana.org/narm under “1995 Job Analysis.” The following list is not all-inclusive, but gives a good overview of the scope of practice: Comprehensive midwifery care for the mother includes a thorough physical examination and complete medical history, and appropriate follow-up exam and history throughout care. Laboratory work is ordered, and screening is done for conditions that might affect the mother or baby during pregnancy or birth. Any significant risk factors identified are thoroughly discussed.
Direct-entry midwives are regulated in 15 states, according to information provided by the Midwives Alliance of North America. Eleven states issue a license - LM or LDM (AR, AZ, CA, FL, LA MN, MT, NM, OR, SC, WA); two states certify midwives - CM or CDM (AK, NH); one registers them - RM (CO); and one “documents” them - DM (TX). There are also 13 states where the practice may be permitted by statutory inference or judicial interpretation, 7 others where a statute exists but licensure itself is not available, 7 where midwifery is not expressly prohibited, and 9 where it is prohibited (Wa-DC, IN, IA, KY, MD, MO, NC, VA, WY). Regulatory bodies include advisory committees, advisory councils, independent boards, and boards which function with or under other groups. Statutes differ from state to state on such issues as prescription rights, referral and transport requirements, and the required relationship with obstetrical backup. Medicaid reimbursement is available in 7 of the licensed states. Nurse-midwives are regulated in all states, the District of Columbia and a number of other jurisdictions such as Puerto Rico and Guam, but even with nationwide licensing, the regulating bodies vary. There are nursing or advanced nursing boards (38 states), joint oversight by nursing and medical boards (5 states), an independent CNM (UT) or midwifery board (NY), a public health or board of health board (3 states), and even two states where the practice is regulated by the medical board alone (NJ and PA). The statutes are reasonably uniform in defining scope of practice, although there are some variations, particularly for independent prescriptive authority and whether or not the CNM is defined as a primary care provider (PCP). CNM services are a federally mandated benefit for Medicaid beneficiaries, although patients may have to “work the system” to get what they want. Third party reimbursement for midwifery is also highly variable. Some payers may reimburse CNMs but not LMs; others will reimburse both. Some policies cover a clinic setting for midwife births but not home births. Obstetricians may find their malpractice insurance rates going up if they provide regular backup for direct-entry midwives (despite their good safety record), so MD backup can be difficult to find for LMs doing home birth. It’s very important for a woman considering a midwife-assisted birth to determine the precise regulatory environment in her state, to clarify any insurance coverage well ahead of time, and to understand and be comfortable with the midwife’s scope of practice and legal requirements for medical consultation and transfer. Direct-entry midwives can and do obtain their education from a variety of sources, including independent midwifery schools, programs in college or university settings, apprenticeship and self-study. In order to bring credibility and accountability to the diversity of educational backgrounds, the Midwives Alliance of North America established the North American Registry of Midwives (NARM) to develop and administer a certification process that includes verification of knowledge and skills through examination of credentials and completion of a written examination and skills assessment. This credential requires training in out-of-hospital births. The process results in the CPM-Certified Professional Midwife credential, which is recognized by many of the licensed states. As a reasonable precaution, if an LM does not have a degree from a midwifery school or program recognized by the Midwifery Education Accreditation Council, then she should have the CPM credential. Best protection for the consumer is to select a midwife with both. Nurse-midwives go through a similar certification process administered by the American College of Nurse-Midwives, which sets the standards by which nurse-midwifery is practiced and accredits nurse-midwifery educational programs. CNMs obtain their nursing degree first and then pursue additional training to become a CNM. The credential is recognized in all 50 states. Typical first office call or visit Limitations Resources |
