Info ~ CaLM’s Standard-of-Care Development Site ~ part 2

by faithgibson on June 11, 2015

in Discussions, Introductory Material

Part 2 ~

CCM’s Standard-of-Care as a placeholder document

As stated earlier, the Collaborative Work Group is developing a standard-of-care for the California community of licensed midwives relative to the post-AB 1308 practice of midwifery. We are currently using the California College of Midwives‘ standards & guidelines (2004 version, updated 2015) as a template that can be responsively customized and tailored to meet the general need by midwives for information and guidance that supports competent practice and community accountability.

The CCM placeholder document was originally developed in 1998 for the California Professional Liability Consortium which provided malpractice coverage LMs & CNMs) practicing in three states (background details in part 3).

As administrator of the Consortium for three years (1998 to 2000), I needed to quickly come up with a legally bullet-proof Standard-of-Care for our 55-member midwives, so I Googled all the published sources in English that I could find, including hard copies i already had. This included historical and contemporary standards of care & practice guidelines as provided in state licensing laws (incl. California’s 1917 and 1993 midwifery licensing laws) and state mfry organizations (incl. CAM’s original 1985 & 1989 Standard-of-Care document), national mfry organizations (MANA, ACNM, NARM-NACPMs) and international organizations in Canada, Netherlands, New Zealand, UK and the ICM (see list of 23 reference at end of Part 3).

I copied 85-90% of the content word-for-word from this legacy material. The other 10-15% represents my attempt to deal effectively with the specifics legal, political and practice issues surrounding community-based midwifery in California. The various published standards-of-care document had very similar content, so I choose what i considered to be the very best version, or conflated the best wording from 2, 3 or 4 versions to create a unique sentence or statement that I believed represented the best of the best. My criteria included economy of words, clarity, informative, understandable, and vocabulary least likely to be abused by regulators or attorneys in an effort to trip-up unsuspecting midwives.

The material and information I redacted from these many resource was originally compiled in 1998 into a 40-page document called Characteristics of Clinical Competency. The 55 insured midwives (including myself) agreed to abide by this formal statement of standards and guidelines for a three years; there were no complaints or legal entanglements relative to the use of these standards.

The Characteristics of Clinical Competency used from 1998 to 2000 and represented 165 midwife-years of practice. As a result of their success, coupled with passage of SB 1950 that mandated the MBC to adopt regulations defining a midwifery standard of care, I reformatted and re-configured the “Clinical Competencies” in 2004 to conform with the California LMPA. The new 52-pages version was renamed the “California College of Midwives’ Standard-of-Care”. The 14-page Standard of Care for California Licensed Midwives (SCCLM) voted on by seated members of the MBC in 2005 (it passed) and adopted into regulation by OAL in 2006 was taken from the longer CCM version.

Redactor” is the technical word for the role I played in tailoring and publishing the Standard-of-Care material. This describes the activity of making subtle changes (redacting) in material authored by other individuals. Redactions increase the value of the material by tailoring it for a specific group or in a modernized form. Historical literature like  Plato, Meditations of Markus Aurelius, or Gilgamesh and the Judeo-Christian bible were all “redacted” many times by many different peoples when translated from their original language. English version translated a long time ago were trans-literations” into modern English.

The goal of the redacting process is to preserve the essence of the original material while making the original text more appropriate or understandable for its intended audience or particular circumstances. My goal as a redactor was to change as little as possible unless a specific legal or political issue required it — for example, provisions of the LMPA,  newly developed technologies and the updating go evidence-based recommendations.

Why should all this ‘legacy’ stuff’ matter in 2015? Because it represents hundreds of thousands (if not millions!) of hours of midwifery experience distilled into wisdom and memorialized in the enduring structure we call a ‘standard of care‘. These published standards and practice guidelines identify the various elements of midwifery as a professional discipline that make for the safe, cost-effective, and compassionate care of childbearing families, and also provides for transparency and accountability of its practitioners.

Publishing a Standard-of-Care is equivalent of a constitution and bill of rights all rolled into one. It is an educational tool that provides dependable guidance to midwives, information for the public, and legal protection relative to the use of standard practices. This is an immense advantage for any midwife who must defend the policies, standards, and guidelines she used as a midwife in a court of law, as it allows her to establish that her practices are consistent with the historic, contemporary and worldwide practice of midwifery as a 21st century professional discipline.

I believe this legacy material has already proved it merit by withstanding the test of time, and thus represents the best of the best. It successfully identifies the core values of midwifery, both historically and as midwifery is practiced worldwide. This is is a legacy (or tradition) we can and should be proud of.

 Vision for a bright new future:

What if the CaLMs’ Standard-of-Care as a collaborative effort represented not just the history and practice of licensed midwifery in California, but also our vision for new or expanded activities that will further support and promote midwifery as provided by Ca LMs?

Updating and tailoring the placeholder Standard-of-Care is actually a very modest goal. The really exciting and interesting aspects of completing this first phase are the opportunities to add new material. In my opinion the place to start is with the evolving scientific evidence for how best to meet the practical needs of laboring women, new mothers and newborns babies. As a published body-of-knowledge, evidence for normalizing normal childbirth in health women is substantially more influential today than is was just a decade ago. New and practice-changing research in various areas of maternity care is now being published several times a year.

An example is the wonderful information on the holistic care of newborns taught by Karen Strange as part of her NRP. This can and should become part of the Standard-of-Care material.

A recent study on management of should dystopias suggests dramatically lengthening the time parameters used to define a SD from 60 seconds to four minutes. This research produced solid evidence that the customary management during a protracted delay in delivery of the body, which is to demand that the mother to push harder and longer, accounts for much of the harm association with SD. Imagine — a peer-reviewed obstetrical journal suggesting that calmness and patience are often the best thing to ‘do’ (i.e not do!) and recommending strategies long been used by midwives.

Another potential area is a formal “opinion statement” developed by the CaLM Standards-of-Care committee that provide guidance for routine postpartum care. The question is whether L&D protocols that required q 15 vital signs (BP, pulse & temp) during the first hour are necessary when the new mother has no excessive bleeding and midwives are present in the same room. This topic recently triggered a lengthy discussion on the Canadian Maternity Care Discussion Group (MCDG hosted by Dr. Michael Klein, professor emeritus family practice medicine, University of Alberta). The consensus of opinion on the MCDG was that L&D protocols should not be ‘binding’ for OOH midwifery care.

Another new opportunity is provided by recently published sources of scientific support for physiologic childbirth practices that allow us to cite and provide references for the principles, policies, and practice guidelines that are already included in our standards of care.

For example, a recently published joint statement by MANA and ACNM acknowledged and promoted the science of physiological management as the evidence-based standard of care for all health childbearing women. What an opportunity to link our principles and guidelines with cited material in this and many other recent publications.

Establishing the scientific foundation of community-based midwifery can be an effective part of normalizing childbirth practice based on the scientific principles of physiologic management. I think the majority of birth activists agree that no healthy woman should ever have to choose between a midwife and an obstetrician, or between home and hospital in order to receive physiologically-based care for normal childbirth. The individual management of pregnancy and childbirth should always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the birth attendant or the planned location of care.

A functional maternity care system would integrate the principles of physiological management with best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women with normal pregnancies; obstetric interventions would be reserved for those with complications or if requested by the mother. This model of ‘best practices’ should apply to all categories of birth attendants (physician or midwife) and all settings (home, hospital or birth center).

Last but not least (and to me, the most exciting) is the possibility of making and posting YouTube videos that publicize information about OOH midwifery care. For example, informative video explanations about prenatal genetic screening, GDM, Rh-negative & RhoGam issues, GBS screening and postnatal issues such as vitamin K administration and the use of pulse oximetry at 24-48 hrs to screen for the 7 critical congenital heart defects.

I think the most important topic to cover with YouTube videos is the general issue of informed consent for OOH midwifery care. A well-made You Tube video could explain how mfry as a professional discipline differs from medicalized care, and provide information on the place-of-birth safety issues, such as the relative risks of laboring in a low medical interventions setting (home and birth centers) vs a high medical intervention setting (the intensive intrapartum unit of a hospital L&D).

The NEJM just published a ‘practitioner-perspective’ article by obstetrical physician Neel Shah on June 5th. It reiterated the new guidelines for the UK’s NHS that recommend healthy women with normal pregnancies give birth at home with a professional midwife.

The tide  is slowly but inexerably turning towards normalizing normal childbirth; CaLM’s Standard-of-Care document can and should be part of this long-awaited paradigm shift.

You have finished reading Part 2

Part 3 ~ Basic Elements for Safer Childbirth ~ addresses the following topics in greater detail:

  • Purpose of a professional standard of care reiterated
  • More about our midwives who volunteered for the Collaborative Work Group
  • Our intentions, plans, goals, why we should bother
  • A walk down memory lane — the original of the CCM placeholder standards
  • S B 1950 ~ legislation mandating the MBC to adopt a mfry standard of care

 ~ Click here for Part 3 

Previous post:

Next post: