Defining the ‘appropriate’ standard of practice by professional midwives
providing care in non-medical setting (independent birth centers & parental residence)
Originally posted in 2004
Background Information: At the time of the negotiations with Senator Figueroa’s office by Citizens for Health Freedom and prior to inclusion of this provision in SB1950 in 2002, the California Association of Midwives (CAM) and the California College of Midwives (CCM ~ state chapter of the American College of Community Midwives) each had developed and circulated practice guidelines which included a Statement of Philosophy, Code of Ethics, Standards of Care and practice guidelines for all phases of community-based midwifery.
The goal of these standards and guidelines as developed by midwifery organizations was to facilitate midwifery practice that was safe, competent and consistent with the history and tradition of midwifery in the US, as well as the midwifery model of care as provided world-wide.
The California College of Midwives’ prior guidelines, entitled “Generally Accepted Practices”, were synthesized standards and practice guidelines from:
- the 1989 revised edition of the CAM guidelines,
- the College of Midwives of British Columbia (Canadian direct-entry midwives),
- elements from the WHO “Care in Normal Birth – a Practical Guide”,
- Dr. Koostermen’s List for domiciliary midwives in Holland,
- The Central Midwives Board handbook, 25th edition, 1962, UK,
- Standards and practice guidelines for the American College of Nurse-Midwives,
- the original Midwifery Statute for California – Section 2505, 1917
- the City of Rochester (New York) 1896 Midwifery statute (which was the origin of statutory language use in the 1917, 1974 and1993 licensing laws in California)
The CCMs’ Generally Accepted Practices were submitted to peer review by practicing midwives and by a physician who attended home births, an obstetrician, a medical anthropologist and an expert on the scientific literature for medical and physiological management. (Donna Driscol, LM, Carol Knight, MD, Don Creepy, OB, Robbie Davis Flloyd, PhD and Henci Goer, author of Obstetrical Myths)
Because the Generally Accepted Guidelines were the most recently complied and most comprehensive (published 1998, updated each year), they were adopted by the Professional Liability Consortium of the American College of Community Midwives. To qualify for this group malpractice policy, all 55 LM and CNM members had to agree to abide by the ACCM/California College of Midwives’ published standards.
In the three years this malpractice policy was in effect, it equated to 165 midwife years/units (55n X 3yrs), with midwives who practiced in three different states (California, Florida and New Mexico). Of the 165 midwife-years, there were just three claims (only one in California), or a claims-rate of less than 2%. By comparison, approximately 10% of obstetricians are sued annually, so the rate of litigation for physiological management is only 1/5th of that for medically interventionist care.
The efficacy of a universal midwifery standard to provide for safe and satisfactory practice by California LMs can be inferred both from the numerical claims history of the professional liability group and the specific incidents. None of the three adverse outcomes were established to be the result of substandard care on the part of the insured midwife.
In particular, the single case in California was a crib death 17 hours postpartum, diagnosed at autopsy as a lethal cardiac anomaly with pulmonary stenosis. Neither the place of birth or the care provided by the practitioner was identified by the pathologist as a secondary or even a minor contributing cause.
Based on the tract record of standards already adopted by professional midwifery organizations, it can be demonstrated that the quality of this criteria and adherence to it by practitioners provides for safe and efficacious midwifery care. It is protective of the consumer, protective of the professional status of the LM and protective of the regulatory agency, reducing the disciplinary burden by lowering the number of incidents that must be investigated and potentially prosecuted by the MBC.
The achievement of these vital goals clearly established the functional quality of universal midwifery standards and guidelines to be an “appropriate” standard for the practice of midwifery in California.
If regulations proposed by the MBC do not meet the technical criteria listed below, they will not meet the practical needs of childbearing women, LMs and the regulatory burden of the MBC. As a result, neither consumers nor organizations can or should support them.