On July 16, 2013 Philosopher Joe (AKA Joe Campbell, Professor of Philosophy at Washington State University) interviewed Rose Huskey (a well voiced equality activist living in Moscow, Idaho) on the subject of Midwifery in Idaho.

Midwifery in Idaho

I am writing to you as a concerned layperson.  I am not affiliated with any political organization, lobbying interest, or health care entity.  In 2014 legislation regarding Idaho direct entry (DEM) aka certified professional midwives (CPM) will be reviewed and, it is to be hoped, allowed to sunset. The current classification of midwives, due to confusing and frankly misleading titles, makes it difficult to understand the credentials of each category and to identify which midwives would be affected by changes in Idaho law, although, in your case I am sure that you are aware of the differences.   If you wish to share this email, please do so.  I have learned that very few laypeople understand the classification of or issues surrounding midwifes in Idaho. The table below briefly summarizes and clarifies the required statutory training and education of each group. I have furnished internet links throughout this letter for independent verification of my statements.

Ending the risky practice of licensing self-educated women will have absolutely no effect on the work or careers of Certified Nurse Midwives.  A certified nurse midwife (CNM) has earned a B.S. in nursing from a regionally accredited college or university.  She has successfully passed a nationally administered exam to qualify as a registered nurse.  The BSN degree encompasses hundreds of hours of academic and clinical training under the supervision of competent professionals. Post-graduate education in midwifery prepares BSN graduates to provide routine maternity care for low risk clients and physician collaboration for complex pregnancies and   deliveries. Most states require at least a master’s level degree to license a CNM.   Nurse midwives are rightfully eligible for privileges in Idaho hospitals and enjoy cooperative and collegial relationships with other health care providers.  CNM education and training stands in sharp contrast to the growing number of certified professional midwives (CPM), a fancy, designer-style name that obscures their lack of formal education and creditable training.  Licensed midwives (LM) who practiced prior to the adoption of any midwife educational criteria in Idaho are grandfathered to continue their midwife work despite the fact that there were no academic or clinical requirements for their practice.

Over the last several months I became aware of CPMs in Idaho and my home town of Moscow.  Many Idaho citizens are familiar with the horrendous “care” offered by the mother – daughter midwife team in Meridian whose ignorant mismanagement of laboring mothers led to the deaths of three infants in the recent past. (It is equally distasteful that sprinkled throughout the website of the Idaho Midwifery Council, a supposedly a professional organization, one finds many photographs credited to Coleen Goodwin.)  I was appalled to learn about the patient neglect of Sherry Riener, a certified professional midwife from Cottonwood, who feels God called her to “catch babies” -  but apparently failed to inspire her to become appropriately educated to safely do so.  Ms. Riener was fined four thousand dollars and placed on two year probation last August for violating “the laws, rules and practice standards governing the practice of midwifery in the state of Idaho" for failing to obtain all the signed consent agreements from N.P. (a non-English speaking patient); maintaining records of consent agreements; providing sufficient information to allow a client to make an informed consent; and violating standards of conduct for midwives.” (Kathy Hedberg, Lewiston Tribune, August 12, 2012.)  The Idaho Midwife Council Board (all of whom are certified professional midwives) continue to advertise the services of Sherry Riener, and she retains her seat on the executive board.  There is no mention of her probationary status.

When I began researching the “credentials” of certified professional midwives I was stunned. CPMs self-educate in obstetrics and apprentice to other CPMs for clinical experience.  In lieu of an academically accredited program they prepare and submit a portfolio describing their experiences for review by their credentialing organization the North American Registry of Midwives.  Six out of seven members of the Board are CPMs.  Their professional organization, Midwife Alliance of North American, reflects a similar lack of academic and/or intellectual diversity. Sixty-one percent of the nine member MANA executive board are CPMs.  Similarly, eight of the nine members of Idaho Midwifery Council Board of Directors (the ninth is a “birth assistant”) are CPMs.  By statute, three of the five board members of the Idaho Board of Midwives are CPMs. )  Because the leadership of MANA, the Idaho Midwifery Council, and the Idaho Board of Midwives, has overwhelming chosen and endorsed a career that requires no accredited academic preparation and celebrates the organization’s position that “endorses diversity in educational backgrounds and practice styles”  there is  little reason to believe that more stringent requirements will ever be implemented. 

Other professions in Idaho respect their clients (and their profession) enough to insist on a more rigorous approach to education and training.  I randomly selected three licensed professions with extracts from the educational requirements and training as a comparison to the minimal educational requirements for CPMs. The hyperlink leads to the statute.

Denturists who fit and manufacture dentures are required to successfully complete two years of college  in  “an educational institution accredited by a national or regional accrediting agency recognized by the Idaho state board of higher education, with a curriculum of which includes courses in oral pathology, physiology, head and oral anatomy, clinical microbiology, clinical jurisprudence, asepsis, and first aid for minor office emergencies”

Cosmetician

 “(c)  Graduation from and completion of a two thousand (2,000) hour course of instruction in a school of cosmetology, or a four thousand (4,000) hour course of instruction as an apprentice covering all phases of the practice of cosmetology.

(d)  Successful passage of an examination for cosmetologist conducted by or acceptable to the board.

Mortician

"(c)  Has completed and received credit for at least sixty (60) semester hours' or ninety (90) quarter-hours' instruction in a duly accredited college or university and has obtained at least a C grade average for all courses of instruction; provided, however, at least three-fourths (3/4) of all of such credits must be for courses in the fields of liberal arts, business or science as defined and specified by the board of morticians.

(d)  Has successfully completed a course in an embalming school accredited by the American board of funeral service education, inc., or such other embalming school as approved by the board of morticians.

CPMs in Idaho are not required to have formal, accredited education in biology, medical terminology, anatomy, physiology, pharmacology, human reproduction, fetal development, or obstetrics.  There are no requirements for post high school education.  Despite these abysmal deficiencies Idaho statues permit certified professional  midwives to administer oxytocin, suture/repair  1^st and 2^nd   degree lacerations associated with childbirth, and to perform a vaginal delivery after a previous Caesarean Section.  Idaho statutes are silent on the practice of placing placental tissue in the new mother’s mouth to control post partum hemorrhage  (please scroll down to the bottom of the page and select Birth Story #4), I’m not.  This New Age – read that magical thinking – approach to what can quickly develop into a life threatening situation is both scientifically ludicrous and esthetically disgusting.  Despite an extensive literature search I found no evidence in juried publications addressing the purported value of the practice.

Many certified professional midwives deliver infants in the client’s home, others own/are employed by a free-standing “birth center.”  Obstetrical and neonate emergencies require immediate, professionally staffed, well equipped facilities to effectively manage a medical crisis.  Certified professional midwives are ill equipped to meet those challenges and indeed may exacerbate them by failing to recognize and promptly act in a deteriorating situation.  Their desire to be perceived as an authority figure, despite the objective truth that they are ill-educated and ill-trained, in the drama and excitement of a birth trumps the welfare of mother and baby.  Direct entry midwives rely on the fact that most labors and deliveries proceed in a relatively straight forward fashion.  And yet, those of us with a passing knowledge of the history of medicine (or who enjoy strolling through old cemeteries) understand that risks associated with pregnancy, labor, and delivery are always present.  There are actuarial reasons that malpractice insurance rates for obstetricians are among the highest in the medical profession.  This is not an issue of concern for direct entry midwives.  They carry no insurance. 

Recently published studies of morbidity and other risks associated with direct entry midwife care emphasize the increased fetal death and maternal death.  The following studies in juried publications address these issues.

Grünebaum, A., McCullough, L.,  Sapra, K., Brent, R., Levene, M., Arabin, B., Cherenak, F. (June 23, 2013).  Apgar Score of Zero at Five Minutes and Neonatal Seizures or Serious Neurologic Dysfunction in Relation to Birth Setting. American Journal of Obstetrics M& Gynecology.  Click here for abstract.

Quoted from the article and sourced here is the following text.

“There is an identifiable pattern in these data for the outcomes of singleton term births: home birth is associated with a significantly increased risk of 5-minute Apgar score of 0 and neonatal seizures or serious neurologic dysfunction compared to hospital birth. When it comes to home birth versus hospital birth, setting is strongly associated with worse outcomes. The increased rate of adverse outcomes of home births exists despite the reported lower risk profile of home birth. The pattern for free-standing birth centers is also identifiable: this setting is associated with increased risk compared to hospital delivery, though not as high risk as home birth. When it comes to freestanding birth center versus hospital, setting is strongly associated with worse outcomes.

It is essential to note significantly increased risks of adverse outcomes from the setting of home and from the setting of free-standing birth centers reported here may be serious underestimations of clinical complications.”

and:

Cheng, Y., Snowden, J., King, T., Caughey, A., (June 20, 2013). “Selected perinatal outcomes associated with planned home births in the United States” American Journal of Obstetrics & Gynecology. Click here for abstract.

and:

Watterberg Kristi, Lead author,  Policy Statement, COMMITTEE ON FETUS AND NEWBORN “Planned Home Births,”  Pediatrics, Official Journal of the American Academy of Pediatrics, on-line publication April 29, 2013.  .  Click here for full paper

CONCLUSIONS

The AAP concurs with the recent position statement of the ACOG, affirming that hospitals and birthing centers are the safest settings for birth in the United States, while respecting the right of women to make a medically informed decision about delivery. ⁷ In addition, the AAP in concert with the ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board. ⁷ “

Please note: The American Midwifery Certification Board does not recognized  Certified Professional Midwives or Licensed Midwifes since both are lay midwifes by definition.

I have no doubt that some direct entry midwives have good intentions. But, and this is significant, those intentions don’t extend to actually becoming appropriately educated and credentialed. Regardless of certified professional midwives’ internalized intentions, the inherent disdain for patient welfare demonstrated by their indifference to formal education and ignorance of science-based medicine is reprehensible. Unlike any other medical occupation in Idaho, midwives are permitted to conduct their business in ways that defy logic and common sense.  Consequently, safe and medically sound outcomes for mothers and infants are in jeopardy.

Perhaps the most succinct indictment of what pretends to be a professional organization can be found here.  The flyer for a meeting in September 2013 reflects the abysmal level of instruction and the brevity of training for medical intervention.  The instructor’s credentials are not listed, nor are the last names of the women teaching treatment of shock and IV therapy and pharmacology.  Annette Lewis, the suturing instructor, is a CPM.  Ms. Lewis also offers housecleaning, babysitting, laundry, cooking, and errand running in her post partum doula service.

This dangerous approach to pregnant women’s health care must stop.  It is my hope that your agency or institution will urge legislators to reconsider the consequences of allowing of direct entry midwives to practice in Idaho.  The risk of death or significant neurological damage to infants should be sufficient to convince legislators to sunset all direct entry midwife statues. Because CPMs carry no liability insurance the financial burden of providing support and long term care for injured- at-birth-babies will fall to the state.  Those costs, in addition to medical and pharmacological support include education, equipment, and the cost of caregiver services.  Most birth related injuries are preventable if the labor and delivery are monitored and attended by educated medical professionals in a medically safe setting. 

Legislation allowing direct entry midwives to bill the State of Idaho for Medicaid patients should be stopped as soon as possible.  Parental poverty is not a reason to provide less than optimal medical care to pregnant women and their babies.  No country in Western Europe permits CPMs to practice.  Canada no longer permits CPMs to practice.  Why?  The answer is clear -  the preventable death and neonate neurological damage from home births and free standing birth clinics is unacceptable, and always will be. 

Please share my concerns with legislators, appointed officials and others who are involved in health care decisions for Idaho citizens.  It is my very strong sense – based in part on my own previously limited understanding of the role, education and training of certified professional midwives - that the majority of Idaho citizens are unaware of the serious issues associated with the licensing of  certified professional midwives and continuing to permit licensed midwives to conduct their business in Idaho.

Sincerely,

Rosemary Huskey