We have received word that HB 695 will not make it out of committee, due to “the overwhelming concern from the people”!! Thank you to everyone who called or emailed the legislators, urged your friends to do so, spread the word in any way, or just sent happy thoughts! [Ok, but I’m enough of a cynic and a skeptic to say, “how do you know a politician is lying? – his lips are moving,” and to still be holding my breath just in case Sen. Bryan, the Chairman of the committee… has it wrong. We may still go down to Jackson on Tuesday, just to be sure.]

This close call has made those of us who are concerned with home birth realize that we need to be PROactive, and not just REactive, so we’re trying to organize and take steps to get legislation that will make CPMs recognized… and also to be able to be reimbursed under insurance and Medicaid. Any thoughts, tips, suggestions or ideas would be more than welcome!! I can speak only with certainty for myself, but I’m fairly sure that most of us in Mississippi are in the same boat, and that is to say, that we have no experience in this matter, so would appreciate the wisdom of those who have “been there, done that.”

I’ve seen that Oregon has what I would call “model” legislation [not that I’ve looked in-depth at this or any other state, so if you know of any good states, or know of anything bad about Oregon’s laws, please fill me in] — basically, midwives can certify, register, get licensed if they choose, but do not have to. If they are licensed, they can carry and dispense certain medicines legally (like IVs and anti-hemorrhagic medicines), which is good.

Frankly, I don’t know much about the midwives that serve Mississippi, except that in my area, they’re awfully scarce. Since MS doesn’t recognize the CPM credential, there isn’t much reason for a MS-based midwife to spend the time and money getting that credential, other than to say, “I did it.” Looking on Google, I’ve seen some CPMs in Mississippi, but for the most part they seem to be living in other states, and serving areas not too far from their respective state lines. My midwives, who were based in Memphis, traveled as far as 75 miles or so from Memphis, which would get a pretty good chunk of North Mississippi. It seems there is a similar situation with midwives in Arkansas and Louisiana. [CPMs are illegal in Alabama.] However, if Mississippi laws were such that there was a reason to become certified (like, to get insurance reimbursement and/or to legally dispense medication), I daresay that more qualified midwives would choose to get certified. Since I know that some midwives don’t like government interference in their business at all, I wouldn’t want the legislation to make non-certified midwives illegal. I’m enough of a libertarian to think that the government shouldn’t be able to mandate who is allowed to attend our births.

The Memphis newspaper The Commercial Appeal ran a story on the legislation today in which they gave the origin of the bill. Apparently, a baby died in a hot tub last year, which is the reason for Mississippi’s horrible infant mortality rates. Seriously — that’s what the Representative who introduced the bill in the House said:

The Mississippi Board of Nursing suggested the legislation because of the state’s high infant mortality rate. Holland says he believes that rate would go down if more babies were born in hospital facilities.

“We had a baby die on the coast last year being delivered in a hot tub,” Holland said.

Uh-HUH. Riiiiight! Ok, if you’ve been reading this blog regularly for any length of time, you know how I always have to dig a little deeper and get the numbers, relying on the CDC linked birth-death certificate query. No, it’s not perfect, but it’ll have to do. Let’s see how many deaths were due to “other midwife” for the latest years they have available, 2003-2005:

I’ll be honest that I don’t know for sure why there were no results for “other midwife.” This may mean 1) there were no births attended by non-nurse midwives; 2) there were births attended by “other midwives” but no deaths in this time period; 3) birth certificates that should have been marked “other midwife” were instead marked as “other” or “unknown,” (or even possibly but not likely as CNM, MD or DO).

So, next step: check out how many births/deaths happened at term, and where (because some of these babies were born as early as 17 weeks gestation, so it doesn’t matter who the attendant is nor where the birth took place; and no midwife I know of would knowingly attend the birth of a baby before 36 weeks gestation — if the woman seems to be in labor, the midwife would tell her to go to the hospital and/or accompany her there herself, so if she was the birth attendant, it would probably be because she happened to be in the back of the car or ambulance with her on the way to the hospital).

Isn’t that interesting? From 2003-2005 there were 3 deaths among babies born at term in an out-of-hospital situation… but there were either 87 or 243 such births, and I don’t know why there is a three-fold difference between the “total” (243) births attended by “other” and the subtotal (87). If somebody knows, I’d appreciate a little illumination.  There is a slight discrepancy (51 births) between the bold total of the in-hospital births and the sum of the subtotals, and this may be attributable to weighting, but I’d say that a three-fold difference is more than the slight difference I would expect from weighting. The only thing I can reason I can think of would be that “other midwife” attended 156 out-of-hospital births with no deaths for these three years. [The reason I suggest that is that I remember doing a query quite some time ago, and realizing that if there were zero deaths in a category, the births just weren’t included in the subtotals, but were in the totals. The query was trying to see how many births shared common factors with my first son’s birth — a home-birth with a CNM in Illinois in 2004 — and when I changed it to “boy only,” the line disappeared because no boys died in such circumstances that year.]

Now for the causes of death for these three babies:

In case you can’t read that, there was one death at 40 weeks, with the baby dying within an hour of birth, due to P21.9 (Birth asphyxia, unspecified); one death of a baby born at 40 weeks gestation, the death occurring after the first month of life, due to R95 (SIDS); and one death in a baby born at 42+ weeks gestation, after the first hour but within the first 24 hours of birth, due to R99 (Other ill-defined and unspecified causes of mortality). While each of these deaths is sad and tragic to the families who lost these babies, it is not realistic to believe that every baby will survive. Yes, it’s possible that these babies may have lived had they been born in the hospital, but that is no where near certain. There were 7 other babies born in the hospital with an MD attending, during this term period (5 at 39 weeks and 2 at 40 weeks) who died of the same code P21.9; and there were 193 babies born in the hospital (with a variety of attendants) from 37-42+ weeks who ultimately died of SIDS in the first year of life; and 9 hospital-born babies who died of ill-defined/unspecified cause of mortality (all with an MD in attendance at their birth).

So, back to the article — apparently some nurses got this legislation sponsored under the pretense that Mississippi’s high infant mortality rate (it’s #1, which is the worst, except for Washington, D.C.) is due to all these babies dying in out-of-hospital births. Who are all these babies dying after having been born outside the hospital?

That’s right — 12 total deaths after an out-of-hospital birth from 2003-2005: 3 “unknown” gestational age, 3 term births, 2 very preterm births (probably had a 65-75% chance of living, with the best possible care, at that gestational age… but they had a doctor for the birth attendant, which makes me wonder if it was really out-of-hospital), 1 extremely preterm birth (a 50/50 chance of living at that age, regardless of what is done), and 3 babies born at 20 weeks — no reasonable chance of living, regardless of what was done. The causes of mortality are prematurity for the two 20-week babies and one of the “unknown”; hydrocephalus for the 24-week baby; breech extraction and “ill-defined/unspecified” for the 27 & 28 week babies attended by doctors; the three causes of death for the term infants previously discussed above; and for the remaining two unknown gestational age, one died by assault (perhaps a teen mom strangled or smothered her newborn baby?), and the other died from some unspecified cause of the perinatal period.

There were a total of 127,602 births during that period in the whole state, with a state-wide infant mortality rate of 10.74 [11.46 for just 2005]. The hospital-birth infant mortality rate was 10.67 [11.40 for just 2005] — still worse than the #2-ranked state for infant mortality in 2005. And that’s assuming that all of these babies who died would have lived if they had been born in hospitals (which is false), and assuming that these births were all attended by midwives, rather than being either planned unassisted or unplanned unassisted births (in a taxi? on the side of the road with EMTs? who knows — you can’t tell from this data). So, leaving out the premature births, there are a total of 4 possible deaths that maybe, just maybe, were possibly somehow due to an intentional planned home-birth with a non-nurse midwife. Nope — four deaths does not change the numbers or ranking for Mississippi when it comes to infant mortality.


12 Responses

  1. Well put Kathy! Bravao. I would like to know who is doing the counting in that office to think that the infant mortality rates would be lower if more babies were born in the hospital. Awesome post. A must share.

  2. You have been a busy girl!! I would like to see anyone who is delivering babies certified by someone! I would like to see them reimbursed and I would like to see them have some type of insurance for their customers.

    By the way, a hot tub can get way too hot. When I did water births I had to take the temp of the water each hour or so. Also took the moms temp too. I would love to see the guidelines that the Brits adhere to. Also want to point out that a guideline is not a rule. Different words, different meaning. Folks get confused by that. Especially staff RNs. You write a guideline and they read “RULE”

    • Yes, it is possible that the hot tub was the cause of death, or a contributing factor; it’s also possible that the death would have occurred under any circumstances (for instance, due to lethal congenital abnormalities, but just *happening* to be born in a hot tub). Someone I know just died a few days ago in her bed, but that doesn’t mean that her bed was lethal — she died of cancer. I get a little irritated (and then a little sarcastic) when people jump to conclusions that are not logically supported by the known facts. Since I don’t know the facts in this particular hot-tub case, I can only speculate.

      However, it is completely unsupported that planned homebirths with non-nurse midwives contribute any great deal to infant mortality in our state. So, while the legislators may have had good intentions to lower the infant mortality rate, they were unfortunately woefully ignorant of the facts.

      This morning, I began daydreaming about appearing before the state legislature with a powerpoint presentation of the CDC Wonder query showing what I discussed in this post. Not that I’m obsessed or anything… 😉

  3. Your comment “I wouldn’t want the legislation to make non-certified midwives illegal.” are exactly my thoughts.
    We have too few home birth options especially in Central MS.

  4. Hey Kathy,
    This link has a history of midwifery in Minnesota. If you scroll down to the mid-1990s, there’s a description of how the current legislation came to be. Also, here’s the (I think) current law governing CPM licensure in MN: Traditional midwives are not required to be licensed in order to practice here. In fact, the one who attended by HBAC was not. There is currently a bill going through the legislature to license free-standing birth centers to be run by CPMs and able to bill Medicaid: Hope maybe some of this helps!

  5. […] stripes are under fire across the country. Kathy at Woman to Woman Childbirth Education shares this joyful news of defeated legislation to ban Certified Professional Midwives in Mississippi. In California, Ina […]

  6. The stat you don’t have and is probably not reported is the number of deaths to babies born in hospital that were transported from a homebirth. Expect them to tell their horror stories and blame their stats on the transports they receive. If they haven’t done so yet, it is coming. Also contact your local homebirth midwives and ask for their stats keeping their identity confidential and also find out their transport rate and the outcomes of the babies that were transported.

  7. That’s a good idea, Jessica. Thank you for your insight.

  8. I thoroughly enjoyed your collection of facts, as it is hard to gt any from our legislation.
    I recently moved to MS from LA and I am an aspiring midwife. I am currently in my own childbearing years so I am doing a lot of book learning on midwifery. I knew what it took to become licensed in LA, but I don’t know anything about MS yet. Apparently there is nothing “written”.
    I did voice my objections to the HB 695 and I also made suggestions for a midwifery board to regulate and license midwives in MS, composed of CNMs, CPMs, OB, and lay/direct entry midwives. There needs to be something.
    I would love to hook up with some local midwives or students. Can you steer me in any direction of info and or connections? I live in Pike County. Thanks!

    • *Current* MS law is basically, “there is no law” — if you’re a woman whose only job is catching babies, you’re legally practicing midwifery, according to state code. The proposed but defeated legislation would make only CNMs legal midwives (which would pretty much make all midwifery illegal, since there are really only a handful of CNMs in the state, and no home-birthing CNMs). A group of us are going to be talking to legislators to be proactive, to get legislation to make CPMs legal (which may or may not make non-certified midwives illegal — I hope not, but I’m not sure what the legislation is). There is a Yahoo group (MSFriendsofMidwives) you can join to get involved in that, and there may be others, like the facebook group I mentioned. Right now, we’re in the infancy stage of this whole thing, so it’s not very cohesive at the moment, but there is some good information in the Yahoo group. There is going to be a group going to Jackson on March 9 from 9-noon to talk to some legislators about proposing pro-CPM legislation, and I hope to be in that group.

      Other general “connections” in this vein would be typical networking — find other “crunchy” or crunchy-leaning people (La Leche League, home-school groups, childbirth educators, doulas), or just talk to mothers of small children to see if they know anybody who gave birth at home, or any doula, etc.

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