July 8, 2013

California midwives push to scrap doctor-supervision requirement for home births

A state bill would loosen regulations on midwives, allowing them to order medical supplies and tests without a doctor's signature. But some advocates want to include a measure freeing midwives from state-mandated physician supervision.

For her first child, Amanda Adams went the conventional route: She checked into a hospital.

Young Hannah arrived without incident, but Adams found the setting intrusive and unyielding for such a private moment.

"The hospital has their standard procedures that you have to fight to get what you want," Adams said, adding that she was unsettled by there being "so many people in and out of the door, and you don't know their names."

So for her next child, Adams took a different approach. Her second daughter emerged not into the scrubbed-white world of a hospital, but into a bathtub in Adams' house, under the watchful eye of a midwife.

Tiny, 1-month old Aaliyah slept quietly in a rainbow sling around Adams' neck on a recent morning at the state Capitol. Around her, under a white tent erected against the sweltering July sun, dozens of children who had also been born at home scampered and dozed.

Their parents had gathered in Sacramento to support a bill that would loosen restrictions on the midwives who had brought the assembled children into the world.

"We realized (the hospital) is a place that's very good at dealing with emergencies and sick people, but we were neither of those, and for a healthy baby, home is a much more peaceful place," said Mary Gindice, who had her first child in a hospital before opting to have her daughter Vivian at home. "I would hate to see that choice taken away from other people in this state."

Midwives say current law does exactly that, denying insurance coverage and creating an untenable relationship with physicians.

The system governing California's licensed midwives poses a predicament: While a 1993 law mandates that home births must be overseen by a supervising physician, doctors, fearful of losing their malpractice insurance, stay away.

The Medical Board of California deals with the stalemate by not penalizing midwives who deliver babies without a physician present.

"We're not going after them with regards to physician oversight at this time at all," said spokeswoman Cassandra Hockenson.

The requirement does, however, block insurance policies – including Medi-Cal, California's insurance program for the poor – from covering midwives. As a result, midwives and advocates say, women across California are being discouraged from pursuing home births.

"The current system just creates all sorts of unnecessary barriers and isn't the best for patient safety," said Shannon Smith-Crowley, a lobbyist for the American Congress of Obstetricians and Gynecologists.

The organization has sponsored legislation in an effort to untangle some of those rules.

Assembly Bill 1308 would allow midwives to order medical supplies and tests without needing a physician's imprimatur. That would lend a level of autonomy that midwives say they deserve.

But while the California Association of Midwives is supporting the bill, the group's president argued that the legislation will not go far enough until it eliminates a physician supervision requirement that she called pointless.

"For 20 years we've been required to have physician supervision, and for 20 years physicians have not supervised us," California Association of Midwives President Constance Rock said at a rally for the bill. "We have 20 years of evidence that we know what we're doing."

At a recent hearing on the bill, Rock said physicians still have a role to play when complications afflict a pregnancy. But the status quo, Rock said, discourages formally cultivating those relationships.

"It prevents us from being in the system, where we want to be," Rock testified. "Many of us have developed individual relationships with physicians that are happy to collaborate with us, who consult with us, who we work closely with, but it has to be underground."

The bill's sponsors also want to ensure midwives are prepared to work with physicians if they encounter health issues with their clients.

Smith-Crowley said they want to guard against a situation in which a woman begins her birth at home, runs into complications and arrives at a hospital, in the middle of labor, where no one knows her or has records on her pregnancy.

"The data shows that home birth can be as safe for the mother as a hospital setting when that care is provided as part of integrated health care delivery," Smith-Crowley said.

Assemblywoman Susan Bonilla, D-Concord, who is carrying the legislation, acknowledged that the bill as currently written doesn't reshape the interplay between physicians and midwives. She said her ultimate goal is to eliminate the physician-supervision requirement.

To that end, Bonilla said she plans to hold meetings during the Assembly's July recess so she can have the bill amended by the time it goes before an appropriations committee, its next stop.

"Trying to have these very difficult conversations around physician supervision is something that could preserve and aid and make it easier, not only for midwives to continue to practice, but for more women to be able to access midwives for their deliveries," Bonilla said.

Midwives also invoke issues with access. California is poised to add a million people to Medi-Cal with the coming federal health care overhaul.

But because supervising doctors aren't present at births, midwives cannot be reimbursed by Medi-Cal. That cuts low-income women off from home births, advocates say.

"Families that are Medi-Cal recipients, if they can't pay out of pocket, then they just don't have access to those services," said Adeola Adeseun, president of California Families for Access to Midwives. "And obviously, the fact that they're on Medi-Cal indicates they don't have $5,000 laying around."

Call Jeremy B. White, Bee Capitol Bureau, (916) 326-5543. Follow him on Twitter @CapitolAlert.

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