OB-GYN-L Messages for November, 2005: A sad commentary on the demise of homebirth in a small town

Dear Gail (and others interested in this topic)

I just want to set the record straight that midwifery in the US varies markedly from state to state. Women do have the right make choices, but the providers get to make choices as well.

I am a CNM who practices hospital and home births in a midwife friendly state. Midwifery is considered a part of routine health (not medical) care in this state so that we can get reimbursed by health insurance companies and regulated so that not just anyone can put up a midwifery shingle. In WA state, there are four types of midwives - CNM's (who often practice in the hospital and birth centers), state Licensed Midwives (LM's) who have midwifery training that guarantee's some level of competence (you can go to midwifery school or naturopathic school for this), Lay midwives (unlicensed, usually trained in the apprenticeship model, often underground, practicing only at home), and a bunch of others from experienced OB nurses that help members of their religious organization for no fee to "Zion midwives" (untrained in any basic medical care including listening to heart tones and CPR) who use prayer rather than the medical model, as well as other somewhat fringe groups with varying skills and philosphies.

The first two groups (CNM's and LM's) are able to obtain malpractice insurance and reimbursement by health insurance companies. Our state sponsors an "affordable" (it is all relative) malpractice insurance plan. The others are not illegal, but cannot be reimbursed and cannot advertise. They often get around this by "renting" their equipment, teaching childbirth classes, labor support or doula services, etc, that allows some reimbursement for services rendered but not for the actual birth. Charging for the birth is considered practicing midwifery (not medicine) without a license.

The down side of all of this is that more and more hospitals and health insurance companies are requiring that an obstetrician sign an agreement to sponsor the midwife. Before this, any physician with OB privileges could sponsor the midwife (ie family physicians, GP's, and others). Before this, we had friendly OB's who would take our calls and referrals but did not have to put their names on the dotted line. With the new rules, we have only a very few physicians in this area willing to assist us, one group of two OB's sponsor 6 CNM's in private practices and no one will sign the sponsorship papers for the one local LM, so she is unable to obtain health insurance reimbursement.

The hospitals are generally midwife friendly for the labor and birth, and do not require continuous monitor, IV's (pts are mostly free to eat and drink as they choose in labor), or other unnecessary interventions. There are jacuzzi tubs in the LDRP rooms (although no water births in hospital yet), and patients are free to wear their own clothes if they like. When I have to transport someone from a homebirth, usually for meconium in the fluid or prolonged ROM, they are treated with respect by the nursing staff. I am able to admit them under my own name. When I send someone in during their pregnancy for non-stress tests, dehydration, premature onset of contractions, etc, the nurses don't question their motivation for wanting a homebirth and the patient is free to be honest about her intentions without fear of refusal of care or humiliation. Our sponsoring OBs are easy to get along with (nice when we call them in the middle of the night) and do not insist on unnecessary interventions (although the hospitals have placed restrictions on VBAC's and they have to be done by our sponsoring OB's, they do have a pretty good success rate). They also have input into our practices, and are able to put some restictions on what they are willing to do. The only significant problem is the care of the newborns. More and more patients are choosing homebirths to get away from the extremely invasive and disruptive treatment of newborns and the increasing hostility to breastfeeding.

I have rarely had a patient who chose a homebirth go back to having hospital births, and I think they would choose unregulated midwives if that was all that was available. Now I am retiring, and the other CNM's are not interested in picking up the homebirth clients. Without physician backup, the lone LM (with no sponsoring OB) is restricted to caring for people willing to pay out of pocket. The majority of homebirths will then be done by the unregulated midwives with varied skills and little documented training who charge smaller fee's, but often are the ones who have their patients extablish care with a local physician for labs, ultrasound, etc. They have to drop people at the ER when they get into trouble and their physician of record is the one that will be called. There will be no regulation or reimbursement. Homebirth will be back in the closet, and only the train wrecks will be documented. Then, sadly, homebirth will have the same bad name here as it does elsewhere.

It would be a great help for midwives and their patients, as well as for the physicians themselves, to foster collaborative relationships in order to avoid the deceptive practices that seem to cause such distress to the OB's on this list, as well as to lobby for legalization of midwifery and homebirth in all states.

Fran Wilson, ARNP
Certified Nurse Midwife
Wild Rose Women's Clinic
Kennewick, WA 99336

From: GA12L@aol.com
Reply-To: ob-gyn-l@obgyn.net
To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
Subject: Re: Homebirths
Date: Mon, 21 Nov 2005 08:46:42 -0600

In a message dated 21/11/2005 14:16:29 GMT Standard Time, igold@cox.net writes:

Most of them however, do not deliver at home, which in the US is not considered part of the mainstream medical care model.

I think you hit the nail on the head with this. If maternity services are considered part of a medical model then there is no hope. Pregnancy is not medical.

And yes, homebirth is very much encouraged over here. It is a woman's right to decide where she can give birth to her baby and we as midwives have a duty to care. Thankfully pregnancy is considered a normal physiological event requiring no intervention until proven otherwise. Women can choose to give birth at home even when they are in labour, if fact a lot do.

Is the decline in homebirth over there due to the fact that it is not encouraged? Don't women have a choice? What if they want a homebirth?

How sad that you have to be on the defensive and are regarded as some kind of witch doctor. I could not imagine working as a midwife if that was the attitude towards us over here. I feel sorry that this is the situation you find yourself in.

Gail

use when must restrict search to only the ob-gyn-l forum...
Enter search keywords:
	Returns per screen: Require all keywords:

A sad commentary on the demise of homebirth in a small town - long, personal