“We’ve never heard such a ruckus”

That was the quote from the Senate Chairman when talking about the recent Mississippi legislation (that died in committee), that would have made all non-nurse midwives illegal in our state. With over 5,000 phone calls, the response was unprecedented. While that may not seem like a lot of phone calls, apparently, it was! Considering that our whole state population is somewhere around 2.5 million, that is 0.2% of the population calling (assuming that each phone call was by a different person, which we know was not the case, since many people called every Senator, or at least, every Senator on the committee).

What started the bill? I’m not sure, but apparently, there was a midwife (perhaps living in Louisiana, perhaps just down in that area of MS) who attended a birth in which the baby died. It’s possible that it was just one of those things, but it’s also possible that she was not as well-trained as she could have and should have been. Since I know no details, and have only a rough idea of what happened, I most certainly cannot pass judgment. Regardless of what happened or “what might have been,” this case led the Board of Nursing to get with a legislator to introduce a bill to make non-nurse midwives illegal. As far as I know, nobody knew about it until it had already passed the House and was in the Senate. Then we spread the word, and “raised a ruckus,” and got it defeated. Yay!

Now, to work.

Last Tuesday, I was part of a group that met in Jackson to begin work on crafting our own legislation to introduce next year that will make CPMs recognized and licensed, and will create a review board to oversee them. I’m not totally sure how that will work, because I’ve just never dealt with that aspect of things before. However, there were some TN CPMs at the meeting that talked about how it worked in their state. You can join the Yahoo group MSFriendsofMidwives to see the latest version of the bill and to stay informed on the process.

Currently in Mississippi, there is only one CPM, although there are several out-of-state CPMs who serve various parts of MS, and many other midwives who could become credentialed and licensed. With licensure and certification not having been required to practice in MS, it could easily be seen by midwives as being an unnecessary use of time and money to get that piece of paper, when there was no risk to not having it and very little if any benefit to getting it. I suppose that saying that you’re a CPM might get you a few extra clients, but it wouldn’t alter your legal status, and you probably couldn’t file for insurance repayment either (I suppose it might be possible, but I highly doubt that without the legal recognition that insurance companies would recognize you either). Under the legislation that will be proposed next year, CPMs would be legally recognized, and current non-certified midwives who can demonstrate that they meet the NARM criteria would be grandmothered in.

So, benefits of the legislation would be that midwives who are currently operating legally and safely in the state will continue to be legal birth attendants, and will also be recognized by the state. I asked about legislation that would make Medicaid be able to pay for such midwives, and was told that the legislation doesn’t specify that, but once CPMs are recognized, that such a step may come in the future — I don’t know if it would need to be a law, passed through the state legislature, or if it’s just one of those things that once they’re legal, they can get set up to file claims, or petition Medicaid to recognize CPMs. Another benefit would be that with credentialing perhaps comes a higher degree of respectability and also recognition. There is a certain something that comes with proof that others recognize the work you’ve done, whether that’s proving you can survive med school and get M.D. after your name, or that you’re a certified piano technician, and become a member of the PTG.

One downside of this particular legislation is that it would make non-certified and non-licensed midwives illegal. Those working on the legislation believe that any measure that allows non-CPMs to practice would be defeated. I can see that, based on the bill that was just defeated, that would have made all midwives (except CNMs) illegal. Yet, midwifery has been unregulated for so long in our state, that I can also see that enough legislators might support the bill, even if it did not criminalize non-licensed midwives. But, it seems prudent to take the safe track. I do wish that legislation such as what is in Oregon could pass, with licensure being optional but having benefits; however, those with much more experience and knowledge about midwifery and legislation are making the suggestions, so I’m going along.

“Why would anyone not want certification??” I can think of a few reasons. Some just don’t like government interfering in your business — it’s simply a libertarian issue. “Government is there to keep the peace, and that’s about it — everything else should be left free and open,” some might say. With certification comes regulation — in some states, non-nurse midwives have become legal, only to be basically legislated out of existence by the laws that made it practically impossible to operate. It’s sort of like the hospitals that have labor tubs, but women can’t use them if their water is broken based on a theoretical but totally unproven risk of infection; and they can’t use them if their water hasn’t broken, lest their water break in the tub, and nobody know it. As long as rules and regulations are sound, then there is minimal problem with them; but when they get to be stupid and over-reaching, they can cause more problems than they solve. In Arizona, the law says that home-birth midwives cannot attend VBACs. If you agree that VBACs should not take place at home, then you’d probably agree that this is good legislation. However, if you think that the risk of adverse events is so small that HBAC is a reasonable choice for women to make, then you’ll probably disagree with the legislation.

John Stossel is in a series of articles discussing the downside of certification (not mentioning midwives at all, and only briefly mentioning doctors). Here are two articles, “The Right to Work,” and “Licensing Madness,” as examples. He makes a pretty good case that certification serves to protect established industries at the expense of those who are equally competent to provide certain services (braiding hair, yoga instructor, writing wills), but don’t have the money (or don’t want to spend thousands of dollars) to certify just for the right to do what they already can do, especially if they’re doing it on the side, or are starting to build up a business. He points out that market forces will serve to weed out incompetent florists at least as well as (if not better than) the lengthy and expensive certification process. When it comes to businesses such as these, I’d have a hard time coming up with a counter argument — the “risk” of a bad florist is that you waste $30 on an ugly flower arrangement, in which case, you’d go tell all your friends and family and neighbors and co-workers to avoid that flower shop, and the florist would soon go out of business. But an incompetent midwife may lead to dead or injured mothers and/or babies, so it’s easier to say that doctors and midwives and such should be regulated and certified.

Still, there are probably some very good healers that could not be certified because they are alternative practitioners. For example, Chris Gardner, who wrote the book The Pursuit of Happyness, which was also a movie by the same name with Will Smith playing him, has an interesting history. If you remember the movie, he became a stockbroker while being homeless much of the time, with his son in tow. That’s only part of the story. When he was in the Navy and for several years afterward, he worked for and with a doctor. While my memory of what all he did is a little fuzzy, he had “great hands,” meaning, he was proficient in the medical work he did. He never went to one class of med school, but he had what it took to do what he did, including operate on people, teach med students how to do the right things — he even had work published in medical journals! But, because he wasn’t a doctor and hadn’t gone to med school, what would have been a promising medical career was necessarily stopped. He didn’t have enough money to become a doctor, and the doctor who employed him couldn’t afford to pay him more. “So, big deal — that’s just what you’ve got to do to become a doctor! We can’t have just anybody calling himself a doctor!” Well, true, but this also kept him from applying his skills and healing a lot of people. Sure, it kept some quacks out of the business of medicine, but it probably keeps some who would be very good doctors from doctoring.

There are definite upsides and downsides to this. Regulation helps to keep bad practitioners from starting a business, although it does not entirely eliminate bad practitioners. However, nothing can. While capitalism is a strong influence in keeping bad practitioners out of business (because people will not willingly spend their money on bad goods or services), they can for a time prosper. And if they’re schmaltzy enough, may be able to keep people blind to their incompetence or poor products or services to stay in business for a while — Bernie Madoff was a master at this (of course, he also blinded them with greed, which is another tangent and topic entirely). We’ve all known people who were certified, licensed, bonded, insured, and/or regulated who were really bad practitioners of their craft or trade. It happens. There are bad apples in every barrel. Regulation can make it so that people don’t have to do their own work to make sure people are really competent, which can be a good thing, or a bad thing if they are lulled to sleep and think that everyone who produces a piece of paper is competent.

As you can see, I’m conflicted about this — mostly because if you’ve got a bad midwife, we’re not talking about losing a little bit of money by not being more conscientious, but perhaps losing your baby’s life. Given enough time, the truly bad will probably be eliminated simply by market forces, but what may happen during that time? How many babies may die? Not something to be talked about lightly. However, we cannot protect people from themselves. Some people are going to choose things that others may think are “woo” (acupuncture, acupressure, magnets, copper, feng shui, craniosacral therapy, chiropractic care, herbs, vitamins, supplements, etc.) — we can’t stop them from doing that. And if a woman thoughtfully considers the matter, and chooses a non-certified midwife, or even just has a few friends over to attend her birth, can we really stop her? Should we? At what point does “society” get to dictate who attends her birth? Recently, there has been a national conference on VBAC (which since you’re birth junkies, you’ve probably heard about, unless you’ve been living under a rock). A similar argument has emerged from the pro-VBAC community, namely, that women have the right to choose how to give birth, and should not be forced into a C-section, even if there is a risk of uterine rupture and perinatal mortality. Does someone else get to choose how women give birth, or is that something that each woman should be able to choose for herself?

I think highly enough of women and our intellect to say that if a woman understands that she is hiring as a midwife someone who has only attended ten births, hasn’t really read too much about birth complications, and has never handled a postpartum hemorrhage or a “slow to start” baby, or any other complication, that she should still be allowed to hire that midwife, knowing the risks. I would want someone more qualified than that, but some women are comfortable with that level of skill and knowledge. Unless the midwife misrepresents herself or her skills, then I just don’t see that “we” should try to save the woman from herself. Others may disagree — it comes down to where on the “libertarian” continuum you find yourself.

6 Responses

  1. I quite like this post. I agree that certification of every little career is a bit ridiculous.

    In Oregon ( my home state ) there is optional certification of non-nurse midwives. I know a number of those folks, and based on what I have seen / heard / discussed with them, certification does not imply competence.

    I do think that going to medical school is prerequisite for being a doctor, however. I had a great deal of clinical experience before I went to medical school, and even had some surgical skills. At that time in my life I thought I had a pretty good handle on medicine. Once I was through medical school I realized that at that time in my life I had bupkus when it came to actual knowledge. I had some black box algorithms that helped me to figure out what was going on and what to do in certain situations. I didn’t really understand what was going on. It took a formal medical education to get me there.

  2. I think you made a fair comment at S and S about some of my posts coming off paternalistic. I’ll consider that in the future. Obviously I can only speak for myself, and what I perceive of my colleagues. Sadly, there aren’t very many of us blogging so I do have to defend the side occasionally though.

    • No, I don’t think it was me. There was somebody else (or maybe a couple of people) who were, um, quite strident in the anti-doctor rhetoric. I mentioned paternalism in the context of doctors not telling women enough information to make true informed consent, but that was said in the spirit of “if the shoe fits, wear it.” I certainly don’t think that every doctor is evil.🙂

      • And, actually, reading some of the comments made me cringe, and I almost posted, “Not all of us birth junkies are like that!”

  3. I am totally for OPTIONAL certification of midwives. However, I don’t think it should be required, and here’s why:

    A little over a year ago, I gave birth to my daughter, hbac, with an unlicensed midwife. The licensed midwives in my state were not allowed to assist me with births of any kind (home or hospital) because I have (EXTREMELY well-controlled) type 1 diabetes. AND, neither of the hospitals within four hours of my house would give me a reasonable opportunity to vbac (and honestly, my hospital-birth-turned-cesarean so traumatized me, that I don’t know if I could have given birth at the hospital again, anyway. But that’s beside the point.). In fact, the only people who CAN assist me are ob/gyns, and I was not even close to being ready to go down THAT road again.

    So, I heard through the grapevine of an unlicensed midwife who might be willing to take me on; I called her up, we talked, and it was a go. I say all of that to say this: if I hadn’t been able to find an unlicensed midwife, I would have either had to undergo an e”r”cs, or birth unassisted–something I was not quite ready to do at that point.

    So optional licensing, definitely! I think it’s important to have that option for women. But required licensing? No–women like me need options, too.

    • Kari, thank you for your input and your story. I agree. However, not all states have restrictions on births that licensed midwives can attend. I know that Arizona will not allow midwives to attend HBACs; other states also may not, or may restrict midwives in other ways, such as no breech, no twins, etc. Licensing does not automatically mean restrictions, although it does make it easier to restrict midwives if they have to be licensed. I would much prefer for licensing to be optional, but the climate seems to be that if there isn’t licensing and regulating of non-nurse midwives, then these midwives will be banned and will then be operating illegally. It seems to be “between a rock and a hard place,” and the non-nurse midwives seem to be preferring licensing. I hope that it is the right thing.

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