Oregon Health Plan (OHP), the state’s Medicaid insurer, will no longer cover planned home and birth center births for women whose pregnancies aren’t classified as low risk, based on newly-established criteria. The Health Evidence Review Commission (HERC), a group of experts designated by the state, came up with criteria that will exclude women with a substantial list of conditions, such as high blood pressure, diabetes, previous cesarean section, multiple gestation (more than one fetus), and various complications in previous pregnancies. Feelings ran high on both sides of the issue, which was described as the most contentious ever to come before the HERC.
The HERC’s decision was based on an exhaustive 100-page evidence review; a review, according to them, hampered by the low quality of the evidence on the safety of planned out-of-hospital births. Actually, there is a paucity of evidence altogether. Studies and statistics from other countries, like the Netherlands, were of limited utility because those countries have more stringent midwifery education and training requirements and non-hospital births are better integrated into the health care system.
Most planned out-of-hospital births in Oregon are attended by what are known as direct-entry midwives (DEM), as opposed to nurse midwives, and a few naturopathic doctors. (We’ll look at the many variations of midwifery in a minute.) Since OHP pays for 23% of Oregon births, the economic impact on direct-entry midwives could be substantial. This effect will be amplified when other insurers, who are expected to follow OHP’s new criteria, change their own coverage rules.
(In this post, we are talking about only planned out-of-hospital births at home or in birth centers. Sometimes, confusingly, the term “home birth” seems to reference both. Also confusing is the fact that some birth centers are connected to hospitals.)
Underlying all of this is an animosity between direct-entry midwives and physicians, many of whom regard them as woefully untrained for the task to the point of being dangerous. The official position of the American Congress of Obstetricians and Gynecologists is that hospitals and birthing centers are the safest place for birth, the latter only if the birth attendants are certified by the American Midwifery Certification Board. (These are overwhelmingly nurse midwives.) The ACOG says it respects the right of a woman to choose home birth, as long as she is properly informed of the risk. The American Academy of Pediatrics endorses this view, with the further admonition that newborns must receive proper pediatric care.
On the direct-entry midwifery side, there is a distinct anti-medicine, anti-vaccination, pro-CAM vibe. (See, for example, the list of recommended websites for pregnancy and parenting of the Oregon Midwifery Council, which includes Mothering Magazine and Holistic Moms Network, whose advisory board includes a rogues gallery featuring Barbara Loe Fisher, a chiropractor, Sherri Tenpenny, and Dana Ullman.) A big emphasis is put on the lack of need for medical interventions, the high rate of C-sections, and the fact that birth is a natural process and women and babies have an “inner wisdom necessary for birth.”
Oregon only recently imposed minimal training requirements for direct- entry midwives, required them to obtain a state license to practice, and permitted OHP reimbursement for their services, motivated in part by some high profile tragedies that occurred during home births. Traditional midwives may still practice without a license but are not covered by OHP. The Oregon Legislature also passed a law requiring birth certificates to record the planned place of birth and attendant type. This allowed for better collection of statistics on the risk of death by attendant type and location.
This collection of data resulted in a startling discovery, one relied upon by the HERC in making its decision to tighten coverage requirements. For 2012:
The term [ 37 weeks’ gestation] perinatal mortality rate for planned out of-hospital births (4.0/1,000 pregnancies) was nearly twice that of in-hospital births (2.1/1,000).
However, when pregnancies that did not meet low-risk criteria were excluded, the perinatal mortality rate dropped to 1.0/1,000. (And, no, that doesn’t mean that non-hospital births are safer than those in the hospital, because the hospital rate includes all births, no matter what the mother’s risk level.)
While non-hospital births accounted for only 4.8% of all births in Oregon for 2012, they included 6.5% of all term fetal deaths and 13.3% of all early neonatal deaths (during the first 6 days of life). A fatality case review discovered that planned birth attendants for these cases were 1 certified nurse midwife, 4 licensed direct-entry midwives, 1 unlicensed midwife, 1 of undetermined licensure, and 1 naturopathic doctor.
Confused about midwifery?
I was too. So, let’s take a detour here to look at the many iterations of midwife in the U.S. By my count, there are seven types: certified nurse midwife, certified midwife, direct-entry midwife, certified professional midwife (of which there are two types), traditional midwife, and naturopathic doctor. (Yes, the latter can be midwives, as you’ll see.) The requirements for obtaining various types of certification are created by the practitioners themselves and do not necessarily correspond with the licensing requirements or scopes of practice for midwives specified by state regulation, although states often defer to these certifying organizations to set the education and training requirements for midwives. (The American Midwifery Certification Board, has a nice chart explaining the differences among several types of midwives.)
To become a certified nurse midwife (CNM), one must have a nursing degree (or be an RN without a BSN who completes additional requirements) and graduate from an accredited university-affiliated nurse midwifery program. This is generally a 3 year program of clinical and classroom education and results in a master’s degree in nursing.
There is a similar program for those who have a bachelor’s degree in another field to become a Certified Midwife (CM), a fairly new type of midwife, which also results in a master’s degree. CNMs are licensed in all states but CMs in only a few. In addition to birth attendance, CNMs and CMs can provide other reproductive care, like annual exams, and have limited prescription privileges, depending on their scope of practice under state law. They practice mostly in hospitals, although some practice in birth centers and will attend home births.
One can become a direct-entry midwife through self-study, apprenticeship or a midwifery school, although one that is not affiliated with nursing education. An organization called the Midwives Alliance of North America sets professional standards for midwifery, but there doesn’t seem to be any test, peer review, or other mechanism to determine whether a midwife is practicing according to the standards. Direct-entry midwives can become licensed or registered in states that allow them to practice, usually by imposing certain educational and in-the-field experience requirements.
A direct entry-midwife can also become what is known as Certified Professional Midwife (CPM), although, in my view, the use of the term “professional” is misleading here. Their education and training can be minimal.
There are two ways to become a CPM under a process set by the North American Registry of Midwives (NARM). Of the two, most CPMs now practicing have gone through what is essentially an apprenticeship, called the “Portfolio Evaluation Process” or “PEP,” which doesn’t even require a high school education. The student works under a midwife preceptor, who must have practiced for at least three years and attended at least 50 non-hospital births. The program is largely on-the-job training, although there is a list of reading materials a candidate is supposed to complete.
The supervising midwife must verify that her student has attended:
- 10 births as an observer;
- 20 births, 20 prenatal exams, 20 newborn exams, 10 postpartum visits as an assistant under supervision; and
- 20 births, 75 prenatal exams, 20 newborn exams, 40 postpartum exams as a primary midwife under supervision.
The student is then eligible to sit for the NARM exam, and, if she passes, must attend 5 more births to become a CPM. That’s it.
Or, a CPM candidate can attend a direct-entry midwife educational program at a school accredited by the Midwifery Education Accreditation Council. (Students who graduate from unaccredited schools must go through the PEP program described above.) There are 10 MEAC-accredited schools, with variations in the degree awarded. Some schools award certificates, another an associate’s degree, still others award bachelors, masters and doctoral degrees. However, like naturopathic and chiropractic schools, none of these schools are affiliated with a mainstream American university. In fact, one of the schools is part of Bastyr, the naturopathic school.
Graduation qualifies one to sit for the CPM exam. (If you are interested in seeing what the exam is like, you can find out here, starting at page 37.) The NARM dictates clinical requirements for CPM candidates who graduate from midwifery school as well, although presumably this takes place during the candidate’s schooling.
Traditional midwives have no particular education or training. According to the Midwives Alliance of North America, they:
believe that they are ultimately accountable to the communities they serve; or that midwifery is a social contract between the midwife and client/patient, and should not be legislated at all; or that women have a right to choose qualified care providers regardless of their legal status.
Finally, there are naturopathic doctor midwives. In some states where they are licensed, NDs can practice what is called natural childbirth attendance with additional education and training. Confusingly, their professional organization is called the American Association of Naturopathic Midwives, while their credentialing organization is called the American College of Naturopathic Obstetrics (ACNO). (Note that the ACNO doesn’t even have its own website; it has a page on the Naturopathic Midwives website.) So, naturopathic midwives practice naturopathic obstetrics, also known as naturopathic childbirth attendance. Go figure. It is indeed interesting that NDs claim their education and training qualifies them to practice as primary care physicians, but with additional education and training, they are qualified to practice as midwives.
The ACNO exam, which is accepted in some states as the credentialing exam for naturopathic childbirth attendance, is a 3-hour test given once a year. To sit for the exam, one needs an ND degree, 100 academic hours of midwifery education at an ND school, and to have attended 15 births. (No, that is not a typo; it’s 15.) The ACNO notes that naturopathic birth attendance certificate programs, available at ND schools, generally require more clinical education, consisting of anywhere from 40 to 100 births. (For a look at naturopathic midwifery/obstetrics/childbirth attendance practice, consult our good friend Orac.)
To be complete, let’s compare the education and training of a midwife to that of an obstetrician. To become board certified, OB/GYNs must graduate from medical school and complete a 4-year residency, plus pass their board exams. The minimum standards for residency include:
- Spontaneous vaginal delivery: 200
- Cesarean delivery: 145
- Operative vaginal delivery: 15
However, according to the Review Committee for Obstetrics and Gynecology of the Accreditation Council for Graduate Medical Education:
Achievement of the minimum numbers of listed procedures does not signify achievement of an individual resident’s competence in a particular listed procedure . . . [They] represent only a fraction of the total operative experience expected of a resident within the designated program length . . . [U]pon a resident’s completion of the program, the program director must verify that he or she has demonstrated sufficient professional ability to practice competently and without direct supervision.
Oregon’s experience
Despite the wide variation in education and training (or none at all), any of these practitioners, except a CM, can supervise the conduct of labor and delivery and provide prenatal, intrapartum (during labor and delivery) and postpartum care in Oregon for any woman, no matter what her condition. OHP’s decision to tighten the restrictions on out-of-hospital births limits insurance coverage only; it has nothing to do with the legal scope of practice.
This has led to some disturbing results. In addition to the statistics I’ve already mentioned, testimony before the Oregon Legislature indicated that, for 2012, the intrapartum and neonatal mortality rate for births where the planned attendant was a direct-entry midwife was 6-8 times higher than the rate for planned in-hospital births. The combined intrapartum and neonatal death rate for home births attended by direct-entry midwives was 5.8 per 1,000. By comparison, the in-hospital rate was 0.6 per 1,000.
However, there were actually no intrapartum deaths at Oregon hospitals for 2012, while there were 4 for non-hospital births, 3 of which were attended by licensed direct-entry midwives. Intrapartum death almost never occurs in a hospital because most fetuses in prolonged distress are delivered by Caesarean section.
Parents whose babies were injured in home births attended by direct-entry midwives have lobbied for changes in the law to limit the direct-entry midwives scope of practice. One of these parents is Kristine Andrews. Direct-entry midwives at a home birth center failed to transfer her to a hospital even though her blood pressure was 140/95, among other errors. After her son, Andrew, was born with cerebral palsy due to lack of oxygen, she met with the midwives, who, in response to her inquiries about what went wrong, asked clueless questions such as whether she subconsciously didn’t want to have a baby. (This news report details another family’s terrible experience with home birth. You can find another here.)
Needless to say, Oregon direct-entry midwives are not happy with OHP’s decision. Especially controversial among midwives are exclusions based on a woman’s having had a previous cesarean section and multiple gestation. With the OHP’s (and possibly other insurers’) newly imposed coverage limits, limitations on direct-entry scope of practice will likely happen as a matter of financial consequences, as women who would otherwise choose direct-entry midwives may well elect to have hospital births so that their expenses are covered.
The new criteria are already having an economic impact. According to news reports and announcements made on birth center websites, several birth centers will close.
Yet, no one can say the HERC review wasn’t thorough. The midwives had a full and fair opportunity to present their case, but their position was rejected. According to Dr. Catherine Livingston, associate medical director for the HERC, their evidence just wasn’t persuasive. Unfortunately, midwives aren’t always up front about the evidence. Research on the safety of home births on the website of the Oregon Midwifery Council is cherry-picked.
As to the midwives’ objection that lack of coverage would take choices away from women who aren’t high risk, Dr. Livingston, acknowledging that some low-risk women would be unnecessarily excluded, replied with a comment well worth keeping in mind when the inevitable “health freedom” argument comes up:
We’re making a policy for a population level, so this needs to be the best it can for the vast majority of the population.
Indeed. We aren’t all special snowflakes whose every wish for accommodation by the health care system must be granted. Especially when costs are being shared, either through taxpayer dollars or private insurance risk sharing, which covers just about all of the health care spending in the U.S.
