Meddling with Midwives

Licensure caught in the legislative birth canal

By MELISSA JELTSEN

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As she sits in the State House, Miriam Khalsa, a midwife from Sherborn, glances at her phone. With two clients expected to give birth soon, she is on emergency call. Khalsa, who has been delivering babies since 1981, is one of several midwives urging Massachusetts legislators to pass a bill that would create a state Board of Registration in Midwifery, bringing different types of midwives under one bureaucratic umbrella, and providing more oversight of their work.

"This will help our profession in general be more legitimate. It helps people to understand what midwives do," Khalsa says of the bill, adding, "It would allow us to know that we are practicing legally."

The bill would also bolster consumer access to midwife services. Today, midwives assist only 7 percent of US births. However, midwives are the primary health professionals for over 80 percent of pregnant women in countries like New Zealand and the Netherlands, which boast low maternal and infant mortality rates.

The American Medical Association (AMA) has attacked the bill, calling it too expansive, as it would set separate gynecological standards by licensing a type of midwife (certified professional midwife) that the AMA doesn't recognize because they are "often self taught and in an unregulated apprenticeship-model."

The bill's sponsor, Rep. Kay Khan, D-Newton, considers the legislation necessary for public safety, since certified professional midwives—who are licensed nationally by the North American Registry of Midwives—currently practice in Massachusetts with no oversight. If the bill passes, they would have to apply for licensure and pass a series of requirements to practice legally in the state. "It will give any of the births currently being done more regulation and oversight," Khan says.

Nurse-midwives, the largest group of midwives in the US, are nationally certified registered nurses who complete a midwifery program and practice in hospitals. There are over 400 nurse-midwives assisting births in Massachusetts hospitals, but current regulations prevent them from being independent practitioners.

Massachusetts is one of six states that require midwives to have "physician supervision," meaning midwives can't admit patients to the hospital, serve on major hospital committees, or document either the revenue they generate or their patient outcomes, because they practice under a physician's name.

Peggy Garland, a retired nurse-midwife who worked for 15 years at Boston Medical Center, is now the head of the Massachusetts Coalition for Midwifery.

"If you go to the website of a major Boston hospital and try to search for midwives, '[they're] really hard to find," notes Garland, adding that the lack of data surrounding the contributions of midwives in hospitals keeps them undervalued. "Midwives by and large have to keep their own statistics."

The US has reached a record level of cesarean sections, peaking at 31 percent in 2006. Massachusetts has a 33-percent C-section rate, over twice the rate by the World Health Organization.

Midwives practice a philosophy of nonintervention, letting the physiological birth progress at its own rate. A 2000 analysis of midwifery research, by Jeanne Raisler of the University of Michigan School of Nursing, found that midwives' clients experienced significantly fewer incidents of cesarean birth, low birth weight and neonatal mortality than physician-assisted births.

Gene Declercq, assistant dean of doctoral education and professor of maternal and child health at Boston University School of Public Health, says the research around midwifery care proves it is an excellent option for low-risk mothers. "Research suggests they take more time, and are effective in screening for high risk and referring those clients to obstetricians," he says. "It's the integrated system that makes the most sense."

Barbara Graves, director of the nurse-midwifery education program at Baystate Health, agrees. "I think midwives are the experts in normal birth, and doctors are the experts in problems," she says. "We work together well."

Graves also noted the cost-savings associated with midwives, which is nothing to sneeze at, considering maternity care represents one-fifth of all US health care expenditures. "The cost of midwives is significantly less than physicians. The C-section rate and epidural rate both have costs associated," she says.

Jamaica Plain resident Robin Hutson had a certified professional midwife deliver her first baby in 2002. "I did a lot of research," Hutson says. "After reading all I could, the midwifery model of care just made sense."

Rep. Vincent Pedone, D-Worcester, who has placed a hold on the bill, said he felt more discussion was needed before he could support the legislation. "I have questions regarding the level of protection and safety for child-bearing women in Massachusetts ... My feeling is that the level of education, training and oversight is not adequate for us to give our seal of approval," he says. "It puts both the mother and baby at risk."

Sources within Khan's office say the bill is unlikely to pass before the end of this session, as it would have to go through both chambers by Thursday.