Y. Tony Yang|Katy B. Kozhimannil
Making a Case to Reduce Legal Impediments to Midwifery Practice in the United States
George Mason University|Minnesota Department of Health|University of Minnesota
december 2014 british national institute health care excellence nice published updated guidelines intrapartum care guidelines present evidence affirming lowrisk childbirths conducted midwives yield similarly beneficial clinical results births delivered obstetricians national institute health care excellence nice 2014national institute health care excellence nice 2014 intrapartum care care healthy women babies childbirth nice clinical guideline 190 available httpwwwniceorgukguidancecg190resourcesguidanceintrapartumcarecareofhealthywomenandtheirbabiesduringchildbirthpdf accessed march 2 2015google scholar included statistical information outcomes midwifeled prenatal childbirth care increased likelihood receiving continuous onetoone care labor women cared midwives recommendations also called increased access information choosing appropriate birth setting home birth center hospital weighing risks benefits making safe decision consistent preferences national institute health care excellence nice 2014national institute health care excellence nice 2014 intrapartum care care healthy women babies childbirth nice clinical guideline 190 available httpwwwniceorgukguidancecg190resourcesguidanceintrapartumcarecareofhealthywomenandtheirbabiesduringchildbirthpdf accessed march 2 2015google scholar working update guidelines stressed need autonomy choices maternity care providers birth settings ensuring safety women infants childbirth prime 2014prime l 2014 midwifeled birth safest straightforward pregnancy onmedicacom available httpwwwonmedicacomnewsarticleaspxidc38422325ec74380b68eb60bd1dc6c47 accessed march 2 2015google scholar despite nice reports focus autonomy information choice report characterized widely news media outlets heralding midwifery safest method childbirth lowrisk pregnancies prime 2014prime l 2014 midwifeled birth safest straightforward pregnancy onmedicacom available httpwwwonmedicacomnewsarticleaspxidc38422325ec74380b68eb60bd1dc6c47 accessed march 2 2015google scholar short report seen national endorsement merits midwifery nationally uniform system health care single step publishing guidelines recommending safe practices lowrisk births potential sweeping impact practice midwifery potentially conferring health economic benefits united states however unified path sweeping change childbirth care exists rather regulatory legal logistical opportunities constraints around midwifery practice many varied owing unique governance state vs federal jurisdiction health care delivery systems health insurers practice models professional associations etc structures perhaps us context nice recommendations considered broadly value catalyzing conversation womens choices broader policy environment health care system ensure appropriate set safe care options available pregnant women making decisions childbirth care important first note united states principles federalism dictate midwiferylike practices health care providersfalls within regulatory power individual states laws concerning midwifery fragmented vary dramatically state state many state laws concerning midwifery serve instance authorize practice provide statewide licensure midwives define practice midwifery relates health care providers within state statutory regulatory requirements however enacted state legislatures promulgated state regulatory bodies derived common law different judiciaries effect reducing midwifes ability incentive practice many states arguably laws latter typethose aimed limiting constraining scope midwifery practicehave impact womens options laws former focused authorizing practice midwifery indeed midwifery throughout united states characterized substantial legal impediments practice restrictions take form restrictive scopeofpractice laws laws regulations whose effects artificially limit practice midwifery laws historically implemented passed premise supporting patient safety placing limits midwifery practice abundance clinical evidence indicates restrictions may actually opposite effect denying women access potentially safe highquality options maternity care sandall et al 2013sandall j soltani h gates shennan devane midwifeled continuity models versus models care childbearing womencochrane database systematic review 2013 cd004667pubmed google scholar johantgen et al 2012johantgen fountain l zangaro g newhouse r stanikhutt j white k comparison labor delivery care provided certified nurse midwives physicians systematic review 1990 2008womens health issues 2012 22 e73e81abstract full text full text pdf pubmed scopus 63 google scholar although states laws unique common limitations practice midwifery include compelled supervision physicians requirements physicians midwives enter written practice agreements limit midwifes autonomy limitations certified nursemidwifes cnm prescriptive powers state california department consumer affairs dca 2011state california department consumer affairs dca 2011 general information nursemidwife practice board registered nursing available httpwwwrncagovpdfsregulationsnprb31pdf accessed march 2 2015google scholar 172 nebraska admin code 104 005 states allow cnms full autonomy practice use range policies may include 1 requiring physician supervision contractual practice cnms exercise prescriptive authority 2 requiring cnms contractual practice agreements physicians certain procedures 3 requiring cnms signed contractual practice agreements physicians overall practice 4 requiring cnms physician supervision overall practice effect laws limit independent scope practice open midwives midwives may practicing top license creating potentially duplicative efforts unnecessary oversight addition scope practice laws varying considerations different categories midwives including cnms certified midwives cms certified professional midwives cpms direct entry midwives dems johnson 2011johnson mc 2011 role midwives nurseled medical homes pdf document available httpwwwmidwifeorgacnmfilescclibraryfilesfilename000000000858role20of20midwives20in20nurseled20medical20homes20411pdf accessed march 2 2015google scholar instance cms newer certification midwifery yet reflected state statutory regulatory structures authorized practice five states states recognize cpm credential requires knowledge experience outofhospital settings many cpms attend births womens homes outofhospital birth centers 11 states provide dems medicaid reimbursement midwives alliance north america mana 2011midwives alliance north america mana 2011 direct entry midwifery stateby state legal status available httpmanaorgpdfsstatechart051111pdf accessed march 2 2015google scholar many states failed pass legislation would mandate private insurers reimburse midwives services rendered american college nursemidwives acnm 2014camerican college nursemidwives acnm 2014c state fact sheet available httpwwwmidwifeorgacnmfilescclibraryfilesfilename0000000049282415statefactsheetspdf accessed march 2 2015google scholar barriers include ability propensity hospitals deny admitting privileges midwives high cost professional liability insurance midwives well restrictions practice may imposed malpractice insurers lack limited midwife representation administration among medical staff leadership reticence private health insurers contract directly midwives reimburse full range services authorized provide applicable state laws regulations pervasive false sentiment midwifery poses dangers mother child american college nursemidwives acnm 2014bamerican college nursemidwives acnm 2014b ensuring access high value providers acnm survey marketplace insurers regarding coverage midwifery services september 2014 available httpwwwmidwifeorgacnmfilescclibraryfilesfilename000000004394ensuringaccesstohighvalueproviderspdf accessed march 2 2015google scholar bushman 2014bushman js 2014 ftc health care workshop project p131207 letter secretary federal trade commission available httpwwwftcgovsystemfilesdocumentspubliccomments2014040008289607pdf accessed march 2 2015google scholar johnson 2011johnson mc 2011 role midwives nurseled medical homes pdf document available httpwwwmidwifeorgacnmfilescclibraryfilesfilename000000000858role20of20midwives20in20nurseled20medical20homes20411pdf accessed march 2 2015google scholar laws specify narrow range services provided midwives example may allowed provide prenatal intranatal postnatal care implicitly denying chance provide general primary care women gynecological care family planning services included within american college nurse midwiferys model scope practice american college nursemidwives acnm 2014aamerican college nursemidwives acnm 2014a definition midwifery scope practice certified nursemidwives certified midwives available httpwwwmidwifeorgacnmfilesacnmlibrarydatauploadfilename000000000266definition20of20midwifery20and20scope20of20practice20of20cnms20and20cms20feb202012pdf accessed march 2 2015google scholar moreover majority states either altogether forbid refuse recognize direct entry midwifery means states actual crime risk litigation limit practice midwifery mere baby catching midwives alliance north america mana 2011midwives alliance north america mana 2011 direct entry midwifery stateby state legal status available httpmanaorgpdfsstatechart051111pdf accessed march 2 2015google scholar large part state regulations restrict practice midwives arose desire place profession oversight ensure public confidence safety prevailing false perception midwifery legitimate clinical practice however evolution profession midwifery understanding public large changed patients today rights responsibilities greater health literacy population 1920s state governments first imposed type licensure requirements midwives intended drive practitioners could pose danger unwitting public declercq et al 1998declercq er paine simmes dr dejoseph jf state regulation payment policies nursemidwife serviceshealth affairs 1998 17 190200crossref scopus 26 google scholar however time come light clear evidence supporting benefits midwifery model care well economic hardships facing health care system revisit policies govern role midwifery us health care system despite historical fears dangers incompetent practitioners midwifery studies actual practice midwifery effectiveness last decades show quite opposite midwifery competently practiced perhaps competent maternity care model available growing body evidence supporting increased access midwifery means toward individuallevel populationlevel benefits terms clinical psychosocial financial outcomes sandall et al 2013sandall j soltani h gates shennan devane midwifeled continuity models versus models care childbearing womencochrane database systematic review 2013 cd004667pubmed google scholar since late 1990s studies consistently shown lowrisk women receive care midwives experience comparableand sometimes better outcomesthan women receive care physicians johantgen et al 2012johantgen fountain l zangaro g newhouse r stanikhutt j white k comparison labor delivery care provided certified nurse midwives physicians systematic review 1990 2008womens health issues 2012 22 e73e81abstract full text full text pdf pubmed scopus 63 google scholar macdorman singh 1998macdorman mf singh gk midwifery care social medical risk factors birth outcomes usajournal epidemiology community health 1998 52 310317crossref pubmed scopus 110 google scholar renfrew et al 2014renfrew mj mcfadden bastos mh campbell j channon aa cheung nf declerq e et almidwifery quality care findings new evidenceinformed framework maternal newborn carelancet 2014 384 11291145abstract full text full text pdf pubmed scopus 678 google scholar sandall et al 2013sandall j soltani h gates shennan devane midwifeled continuity models versus models care childbearing womencochrane database systematic review 2013 cd004667pubmed google scholar furthermore globally studies projected reduction infant mortality rates countries implemented plans make major commitments increasing midwifery practice homer et al 2014homer cs friberg ik bastos dias hoopebender p sandall j speciale bartlett la midwifery 2 projected effect scaling midwiferylancet 2014 384 11461157abstract full text full text pdf pubmed scopus 192 google scholar also evidence midwives produce similar rates positive outcomes doctors hospital settings complicated births homer et al 2014homer cs friberg ik bastos dias hoopebender p sandall j speciale bartlett la midwifery 2 projected effect scaling midwiferylancet 2014 384 11461157abstract full text full text pdf pubmed scopus 192 google scholar top clinical evidence potential greater efficiency similar superior quality care produced using fewer financial resources women receive midwifeled care reduced need higher priced physician time higher priced obstetric procedures longer hospital stays attendant staff resources unnecessarily spent lowrisk births cawthon 2013cawthon l speaker 2013 assessing costs births varied settings meeting video available institute medicine national academies available httpwwwiomeduactivitieswomenbirthsettings2013mar 06day202panel20635cawthonvideoaspx accessed march 2 2015google scholar sandall et al 2013sandall j soltani h gates shennan devane midwifeled continuity models versus models care childbearing womencochrane database systematic review 2013 cd004667pubmed google scholar although social cost bad birth outcomes avoided costs seems united states despite leading world health care spending figured spend wisely enough eliminate risk indeed 2010 us infant mortality rate 61 infant deaths per 1000 live births united states ranked 26th infant mortality among organisation economic cooperation development countries macdorman et al 2014macdorman mf matthews tj mohangoo ad zeitlin j international comparisons infant mortality related factors united states europe 2010national vital statistics report 2014 63 16pubmed google scholar estimated costs approximately 4 million annual us births well 50 billion potentially rising high 66 billion 2013 national partnership women families 2015national partnership women families 2015 cost baby united states available httptransformchildbirthconnectionorgreportscost accessed march 2 2015google scholar nearly universally acknowledged us health care system overburdened costs need find innovative ways create value within us health care system primary motivation behind passage affordable care act continues dominate business decisions policy discussions clinicians administrators researchers policymakers look new ways improve economic efficiency health care system maintaining high standards access quality robinson smith 2008robinson jc smith md costreducing innovation health carehealth affairs 2008 27 13531356crossref scopus 15 google scholar rarely straightforward answer challenge posed triple aim increased quality improved health lower costs field maternity care signs point midwifery recent projections shown 27 reduction maternal mortality rates 10 increase midwifery usage worldwide ten hoopebender et al 2014ten hoopebender p de bernis l campbell j downe fauveau v fogstad h van lerberghe w et almidwifery 4 improvement maternal newborn health midwiferylancet 2014 384 12261235abstract full text full text pdf pubmed scopus 267 google scholar 25 increase midwifery coverage translates 50 reduction maternal mortality 95 coverage could prevent 82 maternal mortalities areas without midwifery coverage ten hoopebender et al 2014ten hoopebender p de bernis l campbell j downe fauveau v fogstad h van lerberghe w et almidwifery 4 improvement maternal newborn health midwiferylancet 2014 384 12261235abstract full text full text pdf pubmed scopus 267 google scholar statisticsalthough generated global contextare startlingly relevant areas united states lack adequate access maternity care including lowincome populations rural communities immigrant racialethnic minority groups 2013 cnmscms attended 817 births 1200 vaginal births types midwives attended additional 071 births centers disease control prevention cdc 2014centers disease control prevention cdc 2014 vital statsbirths available httpwwwcdcgovnchsdataaccessvitalstatsvitalstatsbirthshtm accessed march 2 2015google scholar happily given midwives could potentially attended majority births significant opportunity expanding utilization services savings improved outcomes resulting expansion would significant particularly states medicaid programs cover nearly onehalf births country markus et al 2013markus ar andres e west kd garro n pellegrini c medicaid covered births 2008 2010 context implementation health reformwomens health issues 2013 23 e273e280abstract full text full text pdf pubmed scopus 146 google scholar time come states seriously reconsider seriously potential legal impediments may unnecessarily limit womens choices maternity care provider birth settings first time view put forth led childbirth connection 2010 blueprint action create highquality highvalue maternity care system united states highlighted key research education workforce investments needed increase access midwifery services transforming maternity care symposium steering committee 2010transforming maternity care symposium steering committeeblueprint action steps toward highquality highvalue maternity care systemwomens health issues 2010 20 s18s49pubmed google scholar view recommendations would enhanced focus statelevel policies govern practice midwifery