Part 3 ~ In-depth information for the truly dedicated reader
Reminder ~ The purpose of a professional standard of care is to:
- function as a reliable source of information & guidance for California licensed midwives
- provide information about the professional practice of community-based midwifery to interested parties, including the public, client families, legislative and regulatory bodies
- provide objective criteria for evaluating an individual midwife’s practice
- provide some measure of legal protection to individual midwives who provide community-based midwifery care in California that is consistent with a published professional Standard-of-Care
More about who we are: a small volunteer work-group of Ca LMs that represent ourselves as well as various midwifery-related groups or organizations.
Having had our Standard of Care for California Licensed Midwives (SCCLM) repealed by AB 1308, we all agree on the need to develop a replacement Standard-of-Care document. Members of our work group are willing to spend consider time studying the CCM’s placeholder Standard of Care, which is our current working template. It includes material from CAM’s original standard of care as published in 1895 (updated in 1989), as well as many other excellent sources (see 23 reference documents listed below). The CCM document was revised in 2015 to reflect changes in client consent & restrictions made by AB 1308.
Unfortunately, the updated 2015 version is not yet available on-line, but should be later in the year. In the meantime, the CCM’s current placeholder is available on-line to provide general guidance. It can also be used, abet with specific limitations imposed by AB 1308, to defend a Ca LM’s clinical judgment or practices consistent with its published standards and guidelines.
The collaborative work-group’s hope for 2015-16 is to produce a body of work that can be referenced by any or all Ca LMs, whether or not they are an official member of CAM, California College of Midwives, MANA or any other state or national midwifery organization.
What is our intention? To functionally replace the 14-page Standard of Care for California Licensed Midwives (SCCLM) adopted into regulation in 2006 that was repealed in January 2014 by passage of AB 1308 with a better, more functional version that is in the control of Ca LMs. While the loss of an officially-sacntioned Standard of Care was a shock at the time, many midwives now think it is a fortuitous opportunity for Ca LMs. Because we are free of regulatory restraints, we can and are expanding and customizing the SoC document to include the full range of issues that CaLMs face when providing childbirth services in non-medical settings (i.e. parents’ residence or independent birth centers).
Why bother? The general consensus among Ca LMs is that having an expanded, fully-functional and recognized Standard-of-Care is a good thing for LMs as well as childbearing parents. There are important legal consideration and protections for both midwives and childbearing families. From the practical end, a comprehensive document must cover a wide range of different topics and will therefore include several different sections.
Examples of this material include information on the historical and contemporary professional practice of midwifery as a recognized discipline worldwide, time-tested principles of mfry care, ethicals standards, specified criteria for client selection, informed consent information, and recommendations for consultation, referral, elective transfer of care and urgent transport, and minimum requirements for providing care during the antepartum, intrapartum, PP and neonatal period, plus administrative issues, such as maintaining client charts, incident reports, and termination of client-midwife relationship under circumstances that do not violate the ‘non-abandonment clause of the Standard’s ethical code.
Ultimately, knowledgable people (including legislators) believe it is smarter, easier and all-round better to develop, control the content of, and publish our own Standards, which is exactly what ACOG and other physician groups do, instead of having our Standards determined by the public regulatory process. Control by us as professionals means we are not dependent on “interested parties” meeting to decide what topics will be covered and the nature of the decisions. All the our policies and practices get to stay where they belong — in the hands of Ca LMs as a professional discipline.
Our plan is to post a draft version on the web for comments and feedback by any and all California LMs. After integrating this feedback into a final edition, it will be publish on-line and be available as a printable PDF.
Our goal is that the final version of these collaborative effort will produce a credible, and generally acceptable, Standard of Care that can be voluntarily adopted (in toto or in part) by Ca LMs and used if necessary in legal situations to establish the competency of midwifery care that is in alignment with the published professional standards for the community-based (OOH) practice of midwifery in our state.
A walk thru Memory Lane ~ understanding of the Standard-of-Care process thru historical background and in-depth details
History of the CCM document: The original version was developed in 1998 by me as the administrator of a professional liability consortium. From 1998 to 2000, our group provided malpractice coverage to 55 professional midwives (LMs & CNMs) in Cal, NM, Fla who provided PHB and midwifery care in OOH birth centers. These 55 midwives collectively paid approximately $113,000 each year for one million-three million liability policy. Over the three years, our tiny consortium paid out more than 3 million dollars in premiums.
For me, the take-home message was pretty clear — midwives as a class are not ‘poor’ and it is not helpful to think of ourselves that way. Apparently we are able to raise rather significant amounts of money whenever we make up our minds to do so.
However as consortium administrator I soon realized that our group had no logical way to defend an insured member-midwife in a lawsuit that claimed the midwife’s care was incompetent or negligent. In order to defend against claims of incompetence, we first had to have a standard of care that identified the critical elements of competent practice. Then all our insured midwives had to read carefully and agree to practice under these guidelines. This included a responsibility by the midwife to document and explain any extenuating circumstances that made compliance inappropriate in a particular situation.
I compiled the original version by gleaning information from midwifery textbooks and published examples of midwifery principles, policies, guidelines and protocols used by other groups and jurisdictions. My research also included books offering legal advise about pro-actively preventing claims of malpractice, or at least reducing the risk. The original material was over 100 pages when printed out.
Then I organized this mass of printed material into topics by cutting up each example into its natural segments and piling up like-with-like on my dinning room table. Ultimately, I took the very ‘best of the best’ language for each topic and pasted them together. The idea of being a ‘best’ referred both to the best ideas, and also the best descriptions or ways to communicate the information.
I called my first effort: “Generally Accepted Practices: Characteristics of clinical competency associated with science-based maternity care systems as provided by professionally licensed midwives“. Yep, it was quite a mouthful! A list of the most important sources (23) is included at the bottom of this post.
The track record of the Liability Consortium was evidence of its success. We had only 4 claims out of 150 midwife-years of practice. No case went to court; only one was deemed meritorious and resulted in a $30,000 settlement. Obviously, our med-mal carrier made money on us. Apparently a published standard of care that informs the community-based practice of midwifery is very helpful.
As a result of this insight, I began updating and reformatting the Characteristics of Clinical Competence in 2003 to apply specifically to members of the California College of Midwives. When finished in 2004, the 52- page document was published on-line and available in print as the California College of Midwives’ Standards of Care.
SB 1950 ~ legislation authorizing the MBC to ‘adopt’ regulation defining a midwifery standard-of-Care
The political background to this issue was a protracted three-year food fight over the very idea of a mfry standard for PHB (bitterly opposed by ACOG & CAPLI). Dr. Fantozzi, a Medical Board member who had been appointed chair of the Board’s Midwifery Committee, wanted to end the hostilities and so recommended that the MBC to adopt the entire 52-page CCM Standard as its ‘approved’ standard for licensed midwifery practice.
Frankly I was not happy about this. Once adopted as a regulation, we would not able to amend, change or update our own document without first convincing the MBC to hold a regulatory hearing. Then ACOG and other interested parties could object and CCM member-midwives would never again have control over own standards of care.
However, I was even more concerned that Dr Fantozzi would accept one of the standards being proposed by the midwife-unfriendly MBC staff. These were mainly lists of what LMs were not permitted to do and trivial reasons why CaLMs could not provided care. I still have copies of these proposals and trust me, they were truly awful.
So in September of 2005, I provided a much shorter, 14-page version as fulfilling SB 1950’s requirement that i felt was a more appropriate choice in many ways. Happily the shorter version was much preferred by CAM’s membership, and also acceptable to ACOG’s two representatives, Dr. Ruth Haskins and Shannon Smith-Crowley. That was sufficient for Dr. Fantozzi to agree.
The MBC’s Midwifery Committee (which included Barbara Yarvoslawsky) voted unanimously on September 15, 2005 to recommend that the MBC recognize the CCM’s 14-age version as the midwifery standard of care for Ca LMs. It was re-named the Standard of Care for California Licensed Midwives (SCCLM) and subsequently approved by a vote of the full Board at its October 2005 quarterly meeting. Then the SCCLM was submitted to the Office of Administrative Law and legally adopted into regulation on March 6th, 2006 by the OAL.
However, the AB 1308 in 2013 apparently repealed the statutory authority that allowed the MBC to adopt the SCCLM as a regulation (click here to read my rant on the use of ‘invisible ink’ to achieve such skullduggery)!
During the Midwifery Council meeting held December 4th, 2013, Curt Worden offered to have Board staff edit the 14-page version to reflect the new restrictions of AB 1308. The Mfry Council agreed. The unofficial version was eventually re-named MBC’s “Clinical Guidelines” and posted on the Board’s website in May 2014 as “non-binding, legally unenforceable” source of guidance. This version continues to be available on-line.
Partial list of professional midwifery organizations and state, national and international sources used in compiling the California College of Midwives’ original Standard-of-Care document:
Alaska Statutes and Regulation – AS 08.64 and 12 AAC 14
Arizona Licensed Midwives Rulemaking – 8 AAR 2896, June 18, 2002
California Assoc. Midwives’ Certification, part 3 – Regulation for the practice of midwifery, Standards, Duties and Responsibilities and Guidelines of Practice 1985, 1989
Central Midwives Board Handbook, Incorporating the Rules of CMB; UK, 25th edition, 1962
College of Midwives British Columbia, Model of Midwifery Practice – Philosophy of Care, Ethics, General & Specific Competencies, Standards of Practice, Professional Guidelines, Indications for Midwives to Discuss, Consult & Transfer Care, Statement on PHB (Canada, 1997)
Essential Documents, National Association of Certified Professional Midwives; Philosophy and Principles of Practice, Scope of Practice, Guidelines for Profession Conduct, 8-part Standards of Practice; June 2004 {citations – International Confederation of Midwives Code of Ethics, New Zealand College of Midwives Standards of Practice, Service & Eduction 1988, 1992; Mothers and Midwives: The Ethical Journal, London Books for Midwives, 2003; Midwives Rules and Code of Practice, United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1998
Florida State Statutes for the Practice of Midwifery ~ Responsibilities of the Midwife
From Quackery to Quality Assurance – First 12 Decades of the Medical Board of California, 1995
Midwives Alliance of North America’s Core Competencies for Basic Midwifery Practice
Midwives Alliance of North America’s Standards of Practice, October 1997
New Hampshire Statutes for Professional Midwifery Practice
New Zealand Handbook For Practice, Code of Ethics, 2001
Office of Administrative Law ruling by California Judge Roman in August 1999 ~ Standards of Practice, Duties and Responsibilities acknowledged as appropriate for licensed midwives
Original California Statutory Requirements to Practice Midwifery 1917 to 1993 ~ for state certified (i.e. licensed) midwives under the regulatory authority of the California Medical Board
Principles of Midwifery Practice; Netherlands, Kloosterman (unsure of date but probably mid-1990s)
Standards for the Practice of Nurse-Midwifery; Philosophy, Ethics, Guidelines for Incorporating New Procedures into Nurse-Midwifery Practice, ACNM
Standards & Guidelines Professional Nursing Care of Women & Newborns, AWHONN 1998
Second Stage Labor Management; Promotion Evidence-Based Practice & Collaborative Approach to Patient Care, AWHONN, 2000
Tennessee Association of Midwives ~ Practice Guidelines, adopted January 2001
Texas Statutes for Direct-Entry Midwives
The Obstetrician’s Professional Liability – Awareness & Prevention; Dr. David S. Rubsamen, MD, LL.B 1993
Washington State Criteria ~ Pilot Project for Planned Home Birth
Washington State Standards for the Practice of Midwifery, December 2002