Midwife Calling!

Posted under the
Freedom of Information Act
based on the idea that the America people need to be informed about
the political and economic ramifications of the AMA’s attempt 
to monopolize all aspects of healthcare.

The AMA’s plan it to get laws passed that defined all non-MD practitioners to be “physician-extenders” who are only legally allowed provide care if they are an employee in a doctor’s offic or clinicand work under
the direct supervision of an MD    

REPORT OF THE BOARD OF TRUSTEES (of the AMA)

Limited Licensure Health Care Provider Training and Certification Standards

Duane M. Cady, MD, Chair

 

INTRODUCTION

 

At the 2005 American Medical Association (AMA) Interim Meeting, the House of Delegates (HOD) adopted as amended Resolution 814 entitled “Limited Licensure Health Care Provider Training and Certification Standards.”

 

Resolution 814 calls on the AMA, along with the Scope of Practice Partnership (SOPP) and interested Federation partners, to study the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers and limited independent practitioners, as identified by the SOPP.

 

Reference Committee recommended that the initial resolve be modified to reflect the involvement of the SOPP in conducting the study called for in Resolution 814.

 

Definition of occupations included those that “function in a newly expanded medical support role to the physician in the provision of patient care.”

 

“physician-support occupations” based on ….. the physician’s capability and competence to supervise such an assistant.”

 

{Editor‘s NOTE: this distinction identifies the primary function of  nurse practitioners, nurse midwives, registered nurse anesthetics and physician assistants as “physician extenders” or an ‘assistant‘, rather than a primary provider of care who purpose it to  meet the needs of the patients. Apparently, physicians require more professional support and “help than sick people}  

AMA  HOD rule #160.949 – Practicing Medicine by Non-Physicians.  H-160.949 states that “[o]ur AMA:

(1) …“substitution of a non-physician in the diagnosis, treatment, education, direction and medical procedures where clear-cut documentation of assured quality has not been carried out, and where such alters the traditional pattern of practice in which the physician directs and supervises the care given; {note: and get paid for services he or she did not provide}

 

(3) [AMA] continues to actively oppose legislation allowing non-physician groups to engage in the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision;

 

(4) [AMA] continues to encourage state medical societies to oppose state legislation allowing non-physician groups to engage in the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; and

 

(5) through legislative and regulatory efforts, vigorously support and advocate for the requirement of appropriate physician supervision of non-physician clinical staff in all areas of medicine.

 

SCOPE OF PRACTICE PARTNERSHIP

History

The Scope of Practice Partnership (SOPP) was created by a coalition comprised of the AMA, six national medical specialty societies:

• American Academy of Ophthalmology,
• American Academy of Orthopaedic Surgeons,
• American Academy of Otolaryngology – Head and Neck Surgery,
• American Psychiatric Association,
• American Society of Anesthesiologists,
• American Society of Plastic Surgeons
• Six state medical associations (California Medical Association, Colorado Medical Society, Maine Medical Association, Massachusetts Medical Society, New Mexico Medical Society, and Texas Medical Association).

Members of this coalition (referred to as the “SOPP Steering Committee”) agreed that it was necessary to concentrate the resources of organized medicine to oppose scope of practice expansions by allied health professionals that threaten the health and safety of the public.

 

The SOPP Steering Committee agreed that this would best be accomplished through a wide-range of efforts, including a combination of

• legislative
• regulatory and judicial advocacy
• programs of information
• research
• education.

Moreover, the SOPP Steering Committee was committed to creating a true partnership that operated by consensus and functioned in a cooperative and coordinated manner.

 

The SOPP Steering Committee has met either in person or via conference call quarterly for the last two years.  During this time, it developed various core documents that serve as the foundation for the SOPP.  Three main principles that the SOPP Steering Committee agreed to are as follows:

·      Membership:  Input from all state medical associations and national medical specialty societies will be vital to the viability of the SOPP.  The SOPP and its Steering Committee will be open for participation by any state medical association and/or national medical specialty society represented in the AMA HOD.  The greater the number of members, the greater the resources (both financial and in-kind) the SOPP will have to advance its advocacy efforts.

·      Funding:  SOPP project funding will be derived solely from the annual dues collected from all medical societies participating in the SOPP.  In other words, the amount of dues raised in any given year will dictate the SOPP’s level of involvement in scope of practice initiatives.

The AMA also sought a detailed and exhaustive legal review of the SOPP by its Office of General Counsel (OGC).

 

This was done in order to ensure that the creation of the SOPP was not in violation of any existing antitrust, truth in advertising, election, or lobbying laws. Understandably, this was a very extensive review.  Ultimately, the AMA OGC approved of the underlying principles governing the SOPP. 

 

{{ Faith’s NOTE -> faith: Their lawyers insisted that the phrase “in a manner that threatens the health and safety of the public” always be apart of the phrase “to oppose allied health professions that seek to expand their scope of practice”, so they could pass their unfair business practices off as merely an altruistic concern over ‘patient safety’. }}  

 

From its inception, the SOPP Steering Committee has envisioned that the SOPP’s involvement in scope of practice “campaigns” would be multi-dimensional.  The members of the SOPP Steering Committee had the foresight to see that the SOPP would become involved not only in the individual state legislative, regulatory, and judicial advocacy, but also in programs of information, research and education.  From the very start, the SOPP Steering Committee’s discussions focused on two “top priority” research projects.  Both studies would be extensive and therefore, benefited from the formation of the SOPP and the concentration of the Federation’s resources.  

 

The first of these studies would focus on discrediting access to care arguments repeatedly made by various allied health professionals when seeking to expand their respective scope of practice, particularly in rural states.

 

The second study, and arguably the more extensive of the two, would concentrate on completing educational/training/licensure comparisons of specific allied health professions and the medical profession.  Obviously the second study aligns perfectly with Resolution 814.

 

Official Roll-Out of SOPP

 

The SOPP was officially rolled out at the AMA Advocacy Resource Center’s (ARC) 2006 State Legislative Strategy Conference in January.  Up to that point in time, the SOPP had been favorably received by the Federation**-2 [of State Medical Boards] and was enthusiastically embraced by the attendees of the conference.

 

(2) discrediting access to care arguments made by various allied health professionals, particularly in rural areas of a state;

(3) creating maps that identify the locations of physicians, by specialty, to be used to counter claims that physicians do not exist in certain areas of a given state; and

(4) same as (1) but for the medical profession and specific complementary /alternative medicine professions.

 

It is notable that the draft SOPP Work Plan clearly identifies (1) as its “top priority” for SOPP projects in 2006.

 

Next Steps

 

Since the 2006 State Legislative Strategy Conference, ARC (Advocacy Resource Center) staff has sent letters to the executive directors of all state medical associations and national medical specialty societies recognized by the AMA HOD.

 

These letters included … the SOPP’s core documents, as well as the Statement of Legal Compliance for all medical societies to sign and an invoice for annual dues for all national medical specialty societies and the AMA to process.  ARC staff is currently fielding any questions associated with these memos and processing all dues that are sent by the Federation * [of State Medical Boards].

 

The SOPP Steering Committee considered the draft SOPP Work Plan at its face-to-face meeting on March 13, 2006.  The priority for this meeting was determining the amount of annual dues raised and based on that, identifying SOPP 2006 projects. 

 

Shortly after the SOPP Steering Committee meeting, the ARC team added a new full-time legislative attorney who was hired to focus their attention on scope of practice issues.**-1 

 

This is an exciting addition to the ARC team and signifies the AMA’s continued commitment to addressing scope of practice issues in an effective, collaborative and cooperative manner with its Federation**-2 partners.

 

ARC staff will continue to monitor and track scope of practice developments at the state level, expand its Scope of Practice Campaign when deemed necessary, and work with affected state medical associations and national medical specialty societies, at their request, to oppose allied health professions that seek to expand their scope of practice in a manner that threatens the health and safety of the public. **

 

The Federation [of State Medical Boards] has been energized by the development of the SOPP and the AMA will continue **its work in bringing organized medicine together to fight these scope of practice battles.

 

***  House of Deligates’ Resolution 902  ***

Whereas, Our AMA and the Scope of Practice Partnership are uniquely positioned and well qualified to address this matter of extreme urgency so that our state laws and regulations can be upheld and the authority of state medical boards can be re-established as having full jurisdiction, oversight and authority over medical scope-of-practice activities by mid-level practitioners;

therefore be it

RESOLVED, That it shall be the policy of our American Medical Association that state medical boards shall have full authority to regulate the practice of medicine by all persons within a state notwithstanding claims to the contrary by boards of nursing, mid-level practitioners or other entities (New HOD Policy); and be it further 

RESOLVED, That our AMA, through the Scope of Practice Partnership, work jointly with state medical boards to assist law enforcement authorities in the prosecution of unlicensed medical practice by limited or mid-level practitioners (Directive to Take Action); and be it further

RESOLVED, That our AMA, through the Scope of Practice Partnership, immediately embark on a campaign to identify and have elected or appointed to state medical boards physicians (MDs or DOs) who are committed to asserting and exercising their full authority to regulate the practice of medicine by all persons within a state, not withstanding efforts by boards of nursing or other entities that seek to unilaterally redefine their scope of practice into areas that are true medical practice. (Directive to Take Action)

Whereas, There is a growing trend of non-physician personnel seeking to expand their scopes of work into functions that traditionally constitute the practice of medicine; and

Whereas, The diagnosis of disease constitutes the practice of medicine and requires the integration of the interpretation of a study or studies with clinical experience and training;

AMA Policy H-35.988 furthers the public interest in quality medical care by opposing enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery in all of its branches; and

Whereas, AMA Policy H-35.973 supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care; and 

Whereas, AMA Policy H-35.993 opposes any legislation or program that would provide for Medicare payments directly to physician extenders, or payment for physician extender services not provided under the supervision and direction of a physician; therefore be it 

RESOLVED, That it shall be the policy of our AMA that the Medicare physician fee schedule compensate only authorized persons for the diagnostic interpretation of a specific patient and should not provide payments directly to non-physician personnel working under the supervision or in collaboration of a physician to perform a laboratory study or studies (New HOD Policy); and be it further 

RELEVANT AMA POLICY

H-35.973 Scopes of Practice of Physician Extenders

Our AMA supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care. (Res. 213, A-02)

H-35.988 Independent Practice of Medicine by “Nurse Practitioners”

The AMA, in the public interest, opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery in all of its branches. (Sub. Res. 53, I-82; Reaffirmed: A-84; Reaffirmed: CLRPD Rep. A, I-92; Reaffirmed: BOT Rep. 28, A-03

H-35.993 Opposition to Direct Medicare Payments for Physician Extenders

Our AMA reaffirms its opposition to any legislation or program which would provide for Medicare payments directly to physician extenders, or payment for physician extender services not provided under the supervision and direction of a physician. (CMS Rep. N, I-77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00)

*** Resolutions 204, 205, and 239 ***

Resolution 204 – midwifery scope of practice and licensure
Resolution 239 – midwifery scope of practice and licensure

Your Reference Committee heard testimony supporting increased regulation of home deliveries. Proponents provided important testimony discussing the many negative outcomes and mortality associated with inappropriate and/or unregulated home deliveries. 

Your Reference Committee heard testimony in support of state legislation that helps ensure safe deliveries and healthy babies.  Your Reference Committee therefore recommends adoption of Resolution 205 as amended.

Your Reference Committee heard considerable testimony about regulation and limits on the scope of practice regarding midwives.  

Your Reference Committee agrees with testimony supporting the need for a regulating body over midwives and believes that AMA resources would best be utilized by supporting state legislation reflecting the same.  After hearing the testimony and reviewing the resolution, your Reference Committee recommends adoption of Resolution 204, as amended, in lieu of Resolution 239.

RECOMMENDATION A:

 

Mr. Speaker, your Reference Committee recommends that the second resolve of Resolution 204 be amended by insertion and deletion on page 2, lines 1-2 to read as follows:

 

That our American Medical Association develop model legislation support state legislation regarding appropriate physician and regulatory oversight of midwifery practice, under the jurisdiction of either state nursing and/or medical boards.

 

RECOMMENDATION B:

 

Mr. Speaker, your Reference Committee recommends that Resolution 204 be adopted as amended in lieu of Resolution 239.

 

HOD ACTION: Resolution 204 adopted as amended in lieu of Resolution 239.

 

Resolution 204 asks

 

(1) that our American Medical Association only advocate in legislative and regulatory arenas for the licensing of midwives who are certified by the American College of Nurse-Midwives;

(2) our AMA develop model legislation regarding appropriate physician and regulatory oversight of midwifery practice, under the jurisdiction of either state nursing or medical boards;

(3) that our AMA continue to monitor state legislative activities regarding the licensure and scope of practice of midwives; and

 

(4) that our AMA work with state medical societies and interested specialty societies to advocate in the interest of safeguarding maternal and neonatal health regarding the licensure and the scope of practice of midwives. 

Resolution 239 asks

(1) that our American Medical Association develop model legislation regarding appropriate physician and regulatory oversight of midwifery practice, under the jurisdiction of either state nursing or medical boards;

(2) that our AMA continue to monitor state legislation activities regarding the licensure and scope of practice of midwives and

(3) that our AMA work with state medical societies and interested specialty societies to advocate in the interest of safeguarding maternal and neonatal health regarding the licensure and the scope of practice of midwives.

 

(2) resolution 205 – home deliveries

 

RECOMMENDATION A:

 

Mr. Speaker, your Reference Committee recommends that the second resolve of Resolution 205 be amended by insertion and deletion on lines 24-28 to read as follows:

 

That our AMA develop model state legislation in support state legislation that helps ensure safe deliveries and healthy babies by acknowledging of the concept that the safest setting for labor, delivery and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.

 

RECOMMENDATION B:

 

Mr. Speaker, your Reference Committee recommends that Resolution 205 be adopted as amended.

 

HOD ACTION: Resolution 205 adopted as amended.

 

Resolution 205 

(1) that our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers”; and 

(2) that our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” 

The “put me back, I don’t like it out here” cry of a newborn. I choose this icon as representative of the AMA’s reaction to the merest possibility that it might have to give up it’s historically-based exploitive behavior as described in this essay and its many links to supporting materials.

Easy-to-share Tiny URL: https://tinyurl.com/y3g3v8vk

Mandatory Physician Supervision &
Mandatory Physician Referral: 
Two sides of the very same coin

The name of that ‘coin’ is “borrowed servant/captain-of-the-ship”. For over a century  the US legal system has described the relationship between medical doctors and non-MD assistants as one in which the doctor is identified as the “Captain of the ship”, while nurses and other types of non-MD  ‘helpers’ and ‘assistants’ are considered to be the doctor’s “borrowed servants“.

A more modern version of this idea is provided to us by the AMA in its “Scope of Practice PArtnership” (SOPP) in its House of Delegates Resolution H-35-973″

H-35.973 Scopes of Practice of Physician Extenders

Our AMA supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care. (Res. 213, A-02)

---

NOTE: Longer excerpt of the AMA’s SOPP are provided at the end of this essay, followed by a number of links to historically pertinent documents.

Here is a link from another website that posts the full text of the AMA’s response to Ricki Lake and her film “The Business of Being Born”

AMA Scope of Practice Partnership – Its Hx & anti-homebirth, Ricky Lake bashing resolutions passed by its House of Delegates

A nurse focusing the light for the doctor

Definition of  “Borrowed Servant/Captain-of-the-Ship“

Legal scholars typically refer to this as a legal theory that holds doctors with hospital practice privileges (i.e. independent contractors) financially responsible for the actions of subservient hospital employees acting under the doctor’s authority and/or direction.

For example, it would apply to nurses, aids, orderlies who are carrying out the “Doctor’s Orders”when they provide bedside patient care and circulating and scrub nurses who assisted doctors during  surgical procedures, normal birth, forceps deliveries and C-sections.

In event of a malpractice suit, the “Captain of the Ship”physician (but not the hospital) would be held responsible for monetary damages, even when the harm was the result of errors made by nurses or other assistants who were under control of the doctor/captain.

Now days, hospitals have their own medical malpractice coverage, so this legal principle is rarely used.

However,  “Borrowed Servant-Captain of the Ship” also perfectly reflects the elevated social status and power dynamics of the allopathic medical profession. Seeing all non-physicians as doctor-helpers goes back more than a century ago, to a group of individual who considered themselves to be an aristocracy of white, upper-class, college-educated men who naturally enjoyed the privileges associated with their elevated social status.

This hierarchical model sees nurses, nurse-midwives and, after passage of AB 1308 in 2013, licensed midwives as a subservient class of “underlings” — borrowed servants whose role and “raison d’etre”  is to support the medical profession, no matter how poorly they pay us, or how badly they treat us.

The hierarchical plan of organized medicine is plainly laid out in California’s 1974 CNM licensing law and in the original 1993 LMPA (which also mandated physician supervision provision) and now in the mandatory physician referral in AB 1308.

Obviously there are important differences btw mandated physician supervision and mandated physician referral. The ladder affects midwives less frequently and impacts a smaller number of mothers; nonetheless, the only difference between the two is in the number of people affected.

When it comes to exercising unilateral control  over midwives and childbearing women, mandated referral is the same expression of unearned control over others as was mandatory supervision of Ca LM and continues to be the case for Ca CNMs.

AB 1308 drastically reduced the professional role of Ca LMs by shifting their professional decision-making role to the obstetrical profession

AB 1308 displaced the traditional process of professional collaboration, which began with consultation — between midwives and with other maternity care professionals.

It did this by repealing the Standard of Care of California Licensed Midwives (SCLLM), which defined the role of LMs relative to the clients who wanted obstetrical evaluations or needed to transfer care.

AB 1308 legally replaced its detailed and informative language of the SCCLM with a “one-size-fits-all” mandatory physician referral for “any deviation from norm” (even when not clinically significant & without the mother’s consent), as well as a single list of 26 “Thou Shalt Nots” that was specifically chosen to replace the very informative 14-page SCLLM.

When you read the language of the SCLLM, it’s easy to see its value and what we and childbearing families lost by its repeal. THe SCCLM was authorized by SB 1950 in 2002, adopted by the MBC in 2005, approved by the OAL in March of 2006 and functioned without a glitch during the 8 years that preceded its abrupt repeal by AB 1308.

Here are just a few of the most pertinent excerpts of the SCLLM, beginning with:

Section II: “Brief overview of the licensed midwife’s duties and specific responsibilities to childbearing women and their unborn and newborn babies“

A. The California licensed midwife engages in an ongoing process of risk assessment that begins with the initial consultation and continues throughout the provision of care.

This includes continuously assessing for normalcy and, if necessary, initiating appropriate interventions including consultation, referral, transfer, first-responder emergency care and/or emergency transport.

STANDARD SIX ~ The Midwife shall confer and collaborate with other healthcare professionals, including other midwives, as is necessary to professionally meet the client’s needs.

When the client’s condition or needs exceed the Midwife’s scope of practice or personal practice guidelines, the Midwife shall consult with and refer to a physician or other appropriate healthcare provider.

V. Risk factors identified during the initial interview or arising during the course of care

A. Responsibility of the Licensed Midwife

With respect to the care of a client with a significant risk factor as identified by the client selection criteria in section IV or other science-based parameters, the licensed midwife shall inform the client about the known material risks and benefits of continuing with midwifery care relative to the identified risk factor and shall recommend to the client that her situation be evaluated by a medical practitioner and if appropriate, to transfer her primary care to a licensed physician who has current training and practice in obstetrics.

H Client’s Rights to Self-Determination

In recognition of the client’s right to refuse that recommendation as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal.

If the licensed midwife appropriately documents the informed refusal in the client’s midwifery records, the licensed midwife may continue to provide midwifery care to the client consistent with evidence-based care as identified in this document and the scientific literature.

Capital Building, Sacramento, Ca

How AB 1308 subverted the professional role of Ca LMs

AB 1308 subverted and in certain cases, eliminated the professional role of licensed midwives by declaring that any childbearing woman with a risk-factor or a possible ‘deviation from normal’ is no longer eligible to be the midwife’s client until after she has first become the patient of an obstetrician.

At that point, it’s up to the obstetrical provider to decide whether or not the CB woman will be “allowed” to resume her midwifery care. This decision can be based on anything or nothing, since the law provides no factual guidance and no penalty for malfeasance if the OB should rule her ineligible for midwifery care ‘without merit’ or simply to protect themself from a “vicarious” liability lawsuit.

Notice how all “roads lead (back) to Rome” in that all control and decision-making comes back to MDs as being at the top of the food chain.

A Brief Trip in the “Way-Back Machine” 

“To Cure Without Studying” ~ Historic definition of the illegal practice of medicine:

Historically,  the medical profession has promoted two ideas that have nothing to do with the healing of the sick, or other compassionate functioning a medical doctors.

The first was their insistence that only men had the intellect, unsentimental temperament, and stamina to be doctors.

{Note-2-self ~ add link to 1822 source document by a physician entitled “On Female Practitioners of Midwifery”}

The second was that “medical men” (which is whnt doctors preferred to be called) and only medical men (i.e. allopathically-trained MDs) should have absolute and permanent control over the entity of the practice of medicine.

This was negatively defined by claiming that it was an illegal practice of medicine“to cure without having studied” .

Doctors weren’t arguing that care provided by non-MD practitioner failed to cure the patient or that their care somehow harmed their patients, just that it was illegal for any non-MD to provide any type of health-related care without first graduating from one of the allopathic medical schools approved by the AMA’s Flexner Report on published by the Rockefeller Foundations in 1910. Not only did you have to be a MD but you could not provide any form of care that did not fall into the definition of allopathic medicine — i.e. the use of Rx drugs, surgery and ionizing radiation.

So midwives, naturopaths, herbolists, and many other healthcare disciplines were summarily eliminated from what we now refer to as “healthcare” but in fact is an allopathic medical services delivery system (i.e. MSDS). Our MSDS is great if you are in an accident or develop an acute disease, but what has been ‘systemized’ is not ‘caring’ for our ‘health’.

I’m not suggesting that healthcare providers don’t need to be safe, which is to say knowledgable practitioners — educated, clinically-trained, state-regulated. I’m pointing out that the current hierarchical system is a 19th century dinosaur based on a 19th century gender prejudice that basically said “you girls can’t play with our “boy toys” unless we give you a very special (and limited) dispensation as a nurse acting under the supervision of an MD”.

American obstetrics, which is a surgical specialty, historically defined pregnancy as a 9-month disease that required a surgical cure. When an early 20th century midwife provided care during the biological process of labor and birth, organized medicine saw this “curing” of pregnant women, which was an illegal practice of medicine.

Next Stop on the Way-Back Machine:

Problem: How can the average doctor make his obstetrical medicine practice profitable?

Solution:

First, redefined normal vaginal ‘birth’ as a surgical procedure that can only be “performed” by male physician-surgeons on a labor patient rendered unconscious by general anesthesia and “conducted” with the same level of sterile protocols as used for major abdominal surgery.

Then have the hospital’s low-paid, all-female nursing staff provide all the care during the many hours of labor, as well as the immediate and routine postpartum, while holding L&D nurses responsible for calling the doctor at the right time to ‘deliver’ the baby. {Note: I was an L&D over the course of 15 years and know of what i speak!}

This empowers doctors to get really mad at the nurse (even get her fired) if she didn’t call at precisely the right moment — not too soon (i.e. wasting his time!), and not too late. This is the most critical, as not being in the room when the baby is born legally prevents billing for having “conducted the delivery” under the surgical billing code ‘NSVD’ (normal spontaneous vaginal delivery). 

Below are several historical quoted by obstetricians published in 1911 & 1922. They plainly identify the reason and role of the doctor’s subservient assistants and explain the politics of organized medicine (like ACOG) that are still rule the day.

“The doctor must be enabled to get his money from small fees received from a much larger number of patients cared for under time-saving and strength-conserving conditions;

… he must do his work at the minimum expense to himself, and he must not be asked to do any work for which he is not paid the stipulated fee.

This means … doctors must be relieved of all work that can be done by others  —  nurses, social workers, and midwives.” [1922-A; ZieglerMD, p. 412]

“The nurses should be trained to do all the antepartum and postpartum work, from both the doctors’ and nurses’ standpoint, with the doctors always available as consultants when things go wrong; and the midwives should be trained to do the work of the so called “practical nurses,” acting as assistants to the regular nurses and under their immediate direction and supervision, and to act as assistant-attendants upon women in labor—conducting the labor during the waiting period or until the doctor arrives, and assisting him during the delivery.” [1922-A; ZieglerMD]

In order to follow the natural 60-degree curve of the childbearing pelvis, the obstetrician must to pull straight up towards the ceiling with the forceps in order to deliver the baby’s head

“In this plan the work of the doctors would be limited to the delivery of patients, consulting with the nurses, and to the making of complete physical and obstetrical examinations …  [1922-A; ZieglerMD, p. 413]

“What we must first do is arouse public sentiment and first of all we must have the enthusiastic support and united action of the medical fraternity.…

We feel that the most important change should be in the laws governing the registration of births. The word “midwife” as it occurs, should be at once erased from the statute books. …

We believe it to be the duty and privilege of the medical profession of American to safeguard the health of the people; we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth.

Dr. J. Whitridge Williams, author of “Williams Obstetrics” first published in 1904. After graduating from medical school in 1886, he trained as a gynecological surgeon, then spent 2 yrs in Europe in obstetrical and pathology clinical training programs. He was appointed Chief of Obstetrics at Johns Hopkins in 1899, and Dean of the Johns Hopkin’s School of Medicine in 1911. His book “Twilight Sleep: Simple Discoveries in Painless Childbirth” was published in 1914. His big dream was to find a reliable way to finance a national system of general hospitals like the ones available for 200 years in Western  Europe. However, the AMA would never tolerate anything like the national systems paid for and often run by a national government.  In an effort to generate a new and reliable revenue stream that could be used over the next decades to expand small privately-owned hospitals and build and equip new community general hospitals – one for every population center over 3,000 — and described by Dr. W  “to as ubiquitous if not quite of numerous as libraries and school houses”). To pay for this he came up with the idea of ‘elective hospitalization’. He saw this as creating a large and steady stream of paying customers. The first demographic for elective hospitalizations were healthy middle- and upper-class maternity patients whose families well could afford to pay both the doctors’ fee a AND a hospital bill for a 14-day stay of mother in the maternity ward and the baby in the newborn nursery. Just one hospital labor and birth a day, with a 14-day stay for both mother and baby (total of 28 hospital days per birth) & equated to a maternity department pt. census of  9,800 days per year.  Inventing this income stream was an extraordinarily clever way generate money that would circumvent the politics of the AMA. Organized medicine in the US was opposed to anything that might interfere with its entrepreneurial view of medicine as a very lucrative & ‘no-holds-barred’ small business that could generate consider wealth from private physician fees. The AMA also rejected anything that smacked of “gov’t” meddling in the practice of medicine, which rejection of state or federal gov’t financing. The AMA equated this to gov’t -run ‘socialized medicine’, which it hated. Without access to the non-gov’t sources of revenue from hospitalized healthy maternity patients, Dr. J. W. Williams knew the AMA would have killed his life-long dream — a nationwide system of well equipped , well-staffed general hospitals. From that standpoint, Dr. Williams scheme was masterful and he succeeded beyond his wildest dreams. What this meant for healthy childbearing women is a story for another day (see list of Tiny URLs at the bottom of this post that lead to the Dr. JWW’s personal and professional story)

The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.” {*Boston Medical and Surgical Journal, Feb. 23, 1911, page 261}

In this system, MDs make all the decisions about what is to be done — drugs to be administered (how much and when), whether the patient is ‘allowed’ out of bed, what he or she can eat or do. Doctors convey this to the nursing staff via “Doctors Orders” and various “standing orders” and hospital protocols developed by the MD department chief. These policies and protocols outline what nurses are allowed to do without having to first call the doctor to get a specific “order”.

The nurse holds the patient’s legs, while the doctor does the vaginal exam

The original supervision provision in California’s nurse-mfry law mirrored this same hierarchical system that has began defining the status and power arrangement between male doctors and female nurses since Florence Nightingale invented the modern role of professional nursing during the Crimean War best described as “physician-helpers” or a non-sexual version of a dedicated and dutiful wife who made it possible for battle surgeons to save lives.

‘Essential Workers’, circa 2020

Like mothers, cooks, bus drivers, janitors, and nannies, nurses became what we today (covid-19 era) call ‘essential workers’ — disproportionally-female service workers who are vitally necessary to keep the “system” running — delivery of goods and services, the bedpans hospital patients emptied, babies diapered, buses on time, school cafeterias serving nutritious meals, etc. While the work is literally life-saving, these essential workers are poorly paid, unappreciated, and labor under stressful conditions over which that they have little or no control.

Before returning to the contemporary topic of AB 1308, I must note that our medical services delivery system — most especially the care of hospitalized patients — would come to an instant standstill if the system was required to be fair and equatable —  that is if:

• (a) doctors had to personally provide all the care each of their private patients required over each 24 hour period
  OR
• (b) had to pay wages of equivalent value to nurses and other employees that make the hospital system work 24 hrs a day, 365 days a year. It should be noted that access to all these services are totally free to MDs with hospital practice privileges. Think of all the services a major airport provides to the people who pass through it and yet pay nothing for all its amenities.

Jumping 150 years ahead to present time, modern-day nurse-midwives are legally permitted to be “independent contractors” instead of just employees for a doctor or hospital, but idea of ‘independence’ for nurse-midwives stops there.

In order to keep these ICs (independent contractors) in their ‘appropriately ‘ subservient place in the medical hierarchy, CNMs are only allowed to provide midwifery care while working under the thumb a supervising obstetrician. If the owners of those “thumbs” refuse to supervise, CNMs in California cannot attend births or otherwise legally practice midwifery.

The CMA achieved this great feat by mandating a written “practice agreement” in which each supervising obstetrician defines what the nurse-midwife he or she supervised could and couldn’t do, who she could provide care to and also outline the circumstances in which the CNM must “call the doctor” to get permission to provide (or continue providing) care. This included being ordered by her supervising obstetrician to refer or transfer care or have her client admitted to the hospital OB department, even if the mother did not voluntarily consent to this course of action (ex. 42 wks w/ normal AFI and reassuring fetal heart rate).

AB 1308 achieved many of the same goals as the 1974 CNM law by negating the inherent independence in the LMPA as written by Senator Lucy Killea in 1993 and putting the profession of licensed midwifery under the medical profession’s hierarchal system in the same subservient status as nurses and California nurse-midwives.

The professional independence in the original SB 350 (LMPA) was conveyed in statutory language that defined our scope of practice as “attending cases of normal childbirth“ (as well as authorizing antepartum, postpartum, neonatal, and ‘inter-conceptional’ care & family planning).

SB 350 also limited the practice of licensed midwifery to essentially healthy CB women who were not suffering from any clinically significant (i.e. present-tense) complication, in which case immediate transfer by the midwife to physician care was required.

After having used the descriptive phase “cases of normal childbirth” to define our scope of practice, SB 350 identified ‘abnormal‘ childbirth the limit of that scope of practice. This was defined as any situation that called for the use of “artificial, mechanical and forcible means”. Employment of them is considered to be a practice of medicine. The LMPA plainly states that the “license to practice midwifery does not permit the holder to practice medicine or surgery“.

AB 1308 took control away from mothers by totally ignoring patient autonomy and rights of informed consent and informed refusal. It drastically diminished the professional status of licensed midwifery by cannibalizing the LMPA’s scope of practice, eliminating the Standard of Care for California Licensed Midwives (SCCLM — SB 1950) and substituting a totally negative list of 24 ‘no-no’s (what LMs can’t do). A list of what midwies CAN’T DO is neither a standard of care, or a useful practice guideline.

This statutory scheme of ANB 1308 eliminated the midwife’s professional decision-making process that traditionally included the decision to consult with an appropriate professional (OB, other MDs, or another midwife) when a client’s situation or health status required additional information (“two heads are better than one”), or possible referral or transfer of care might be needed.

Not only are midwives aware that we don’t ‘practice medicine’, we also don’t want to practice medicine, which is why we trained in midwifery instead of going to med school.  We want is to be a part of the mainstream healthcare system, with collegial connections to all kinds of doctors and nurse-midwives, other practitioners and medical services.

Conclusion:

Ultimately, AB 1308 gave the obstetrical profession a statutory tool that recreated the social structure and power dynamics in which the physician is legally identified as “captain of the ship” who “gives the orders” and midwives (CNMs or LMs) are the “borrowed servants“.

Personally, I think this whole system of underpaid, unappreciated “borrowed servants”/essential workers who serve at the pleasure of a system that disproportionately benefits and financially rewards medical doctors should be dismantled, including but not only the issues that concern mothers and midwives.

Links to Pertinent Documents and other Reference

EXCERPTS  from the AMA‘S 2006 “Scope of Practice Partnership“ and links to their 2020 boast of “victory” in more than a dozen states, where they got the state legislatures to pass “physician extender” laws the legally define the role of nurse practitioners, nurse midwives, physical therapists, podiatrists,  optometrists, psychologists, and several other non-physician practitioners as a class of indentured servants who are no longer professionals in their own right but are to function as “physician extenders” — that is, whose primary function is to serve the medical profession and only secondarily to serve their patients and the public:

RELEVANT AMA POLICY ~ Scope of Practice Partnership ~ HOD’s Resolutions

House of Delegate-160.949 – Practicing Medicine by Non-Physicians: states that “[o]ur AMA:

(1) urges all people, including physicians and patients, to consider the consequences of any health care plan that places any patient care at risk by substitution of a non-physician in the diagnosis, treatment, education, direction and medical procedures where clear-cut documentation of assured quality has not been carried out, and where such alters the traditional pattern of practice in which the physician directs and supervises the care given;

(4) continues to encourage state medical societies to oppose state legislation allowing non-physician groups to engage in the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; and

(5) through legislative and regulatory efforts, vigorously support and advocate for the requirement of appropriate physician supervision of non-physician clinical staff in all areUas Uof medicine. (Res. 317, I-94; Modified by Res. 501, A-97; Appended: Res. 321, I-98; Reaffirmation A-99; Appended: Res. 240, Reaffirmed: Res. 708 and Reaffirmation A-00; Reaffirmed: CME Rep. 1, I-00).”

H-35.973 Scopes of Practice of Physician Extenders

Our AMA supports the formulation of clearer definitions of the scope of practice of physician extenders to include direct appropriate physician supervision and recommended guidelines for physician supervision to ensure quality patient care. (Res. 213, A-02)

H-35.988 Independent Practice of Medicine by “Nurse Practitioners”

The AMA, in the public interest, opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery in all of its branches. (Sub. Res. 53, I-82; Reaffirmed: A-84; Reaffirmed: CLRPD Rep. A, I-92; Reaffirmed: BOT Rep. 28, A-03)

H-35.993 Opposition to Direct Medicare Payments for Physician Extenders

Our AMA reaffirms its opposition to any legislation or program which would provide for Medicare payments directly to physician extenders, or payment for physician extender services not provided under the supervision and direction of a physician. (CMS Rep. N, I-77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00)

Bibliography and References: set #2

Link to the end of an original essay entitled:

The Debate on Health Care Policy Reform ~ an exercise in pseudo-journalism

Links to PDF, beginning of Internet version, and other important topics:

PDF version to print or send to your Kindle of read on a smart phone with Kindle app

See Table of Contents & Links to each specific topics  (separate page)

Five-Point Wrap Up:
The ABCs of a Political Action Plan
Excerpts from background materials:

Short-cut to: part 2, part 3, part 4, part 5, part 6, Wrap-up, references & background material

Tell-A-Vision for the 21st Cent

Links to Dr. J. Whitridge Williams ~ Inventor of “elective hospitalization”, staring with middle- and upper-class white maternity patients whose families could afford to pay for a hospital birth, which included 14 days of “lying-in” care after the baby is born. 

Synopsis of Dr. J. Whitridge Williams’
‘Plan’ to finance a nationwide system of general hospitals using hospital-based maternity care as the “cash cow”

His well-meaning plan was to finance the replacement or incorporation of 8,000 two-to-ten bed privately owned hospitals run by one or two doctors as ‘for profit’ businesses, using the revenue generated by electively hospitalized healthy maternity patients, which cost very little to care for but can be charged the same daily fee as very sick patients that need a lot of attention from hospital employees and utilize a lot hospital supplies, equipment and services.

Dr. J. Whitridge Williams, author of “Williams Obstetrics” first published in 1904. After graduating from medical school in 1886, he trained as a gynecological surgeon, then spent 2 yrs in Europe in obstetrical and pathology clinical training programs. He was appointed Chief of Obstetrics at Johns Hopkins in 1899, and Dean of the Johns Hopkin’s School of Medicine in 1911. His book “Twilight Sleep: Simple Discoveries in Painless Childbirth” was published in 1914.

His big dream was to find a reliable way to finance a national system of general hospitals like the ones available for 200 years in Western  Europe.

However, the AMA would never tolerate anything like the national systems paid for and often run by a national government.  In an effort to generate a new and reliable revenue stream that could be used over the next decades to expand small privately-owned hospitals and build and equip new community general hospitals – one for every population center over 3,000 — and described by Dr. W  “to as ubiquitous if not quite of numerous as libraries and school houses”).

To pay for this he came up with the idea of ‘elective hospitalization’.

He saw this as creating a large and steady stream of paying customers. The first demographic for elective hospitalizations were healthy middle- and upper-class maternity patients whose families well could afford to pay both the doctors’ fee a AND a hospital bill for a 14-day stay of mother in the maternity ward and the baby in the newborn nursery. Just one hospital labor and birth a day, with a 14-day stay for both mother and baby (total of 28 hospital days per birth) & equated to a maternity department pt. census of  9,800 days per year.

Inventing this income stream was an extraordinarily clever way generate money that would circumvent the politics of the AMA. Organized medicine in the US was opposed to anything that might interfere with its entrepreneurial view of medicine as a very lucrative & ‘no-holds-barred’ small business that could generate consider wealth from private physician fees. The AMA also rejected anything that smacked of “gov’t” meddling in the practice of medicine, which rejection of state or federal gov’t financing.

The AMA equated this to gov’t -run ‘socialized medicine’, which it hated. Without access to the non-gov’t sources of revenue from hospitalized healthy maternity patients, Dr. J. W. Williams knew the AMA would have killed his life-long dream — a nationwide system of well equipped , well-staffed general hospitals. From that standpoint, Dr. Williams scheme was masterful and he succeeded beyond his wildest dreams. What this meant for healthy childbearing women is a story for another day (see list of Tiny URLs at the bottom of this post that lead to the Dr. JWW’s personal and professional story)

Easy Shortcut to share –> https://tinyurl.com/y8pgewkg

You can link to each post or start with the “Intro” and link each of the following posts at the bottom to download next part.

Intro to 8-part series https://tinyurl.com/y8pgewkg

1 Intro to an 8-part series on Dr. Williams’ 1914 book “Twilight Sleep”: Simple Discoveries in Painless Childbirth”

2 Part 1: The Dream, the Motives, the Methods & Enduring Impact of 1914 book “Twilight Sleep ~ Simple Discoveries in Painless Childbirth ~ by famous American obstetrician: Part 1-a ~ Overview

3 The Dream, the Motives, the Methods & Enduring Impact of 1914 book “Twilight Sleep ~ Simple Discoveries in Painless Childbirth ~ by famous American obstetrician: Part 1 ~ Overview Easy-to-share Tiny URL >>> https://tinyurl.com/ycee9xv7

4 Dr. J.W. Williams: Part 2 ~ Inventing the Economic Engine for America’s private and corporate-owned Hospital System

Sorry, but you must click the link below for 2b instead of the post’s actual title: http://faithgibson.org/dr-j-w-williams-part-1-b-inventing-the-economic-engine-for-americas-private-and-corporate-owned-hospital-system/

5 Dr J. Whitridge Williams: Part 3 Elective Hospitalization ~ the basic economic unit for engine for America’s private system of hospitals

6 Dr. J. Whitridge Williams: Part 4 ~ Selling his odd ideas about childbirth to the public & philanthropists

7 There is a separate Tiny URL for Part 2-a ~ Dr. JWW’s Little Book and the Pentagon Papers  <https://tinyurl.y8udohl6>

8  Dr. J. Whitridge Williams’ Little Book, the Pentagon Papers & movie “The Post”: Part 5 ~ Intro ~ profound harm caused by Twilight Sleep & Genera Anesthesia

9  Dr. J. Whitridge Williams’ Little Book & the Pentagon Papers: Part 6 Numbers don’t lie

The adoring eyes of the breastfeeding infant,
as it gazes up into his/her mother’s eyes while lying peacefully in her arms, safe and secure. This is one of the best way to prepare a child so he or she can grow into intelligent and capable adult citizens, able to do his part in keeping our democratic country strong and

This is the true purpose and goal of the art and science of traditional, community-based, family-oriented midwifery!

AMA beware — Midwives, and dozens of other non-physician practitioners, will no longer quietly take our seat in the back of the bus, to be ‘seen and not heard‘ as a discriminated category of disenfranchised second class citizens.

We refuse to let your organization spend millions each year in illegitimate and illegal efforts to shore up an illegal monopoly by lobbying state legislature to pass newly restrictive licensing laws that define non-physician practitioners as “physician-extenders”, to function like a 19th century subservient wife or indentured servant.

Over the last 2 centuries, the allopathic medical profession in the US has developed for unexplained reasons, into a culture of  harassment, a circumstance that historically begins in medical school when professors insult, belittle and upbraid medical students and those students quickly realize that uncivilized and insulting behavior

Work-N-Progress

This post is a web “home” to provide midwives and childbirth activists with links to educational, scientific or political information useful to defending normal childbirth and the midwifery profession against the constant and self-serving campaign by organized medicine to used its status and economic resources to influence the public discourse in order to promote an escalating model obstetrical intervention in normal childbirth, while using these same resource to suppress and eventually eliminate the independent practice of midwifery.

This information include historical and contemporary documents), scientific studies, government documents (such as produced by the MBC) and many other types of printed materials (include political essays written by me) that help Ca LMs to defend their professional status (esp. the scope of practice and client’s right of informed consent and refusal) and to counter-act the efforts by organized medicine to usurp the rights of mentally competent adults (i.e. the ability of healthy childbearing women to decline unwanted medicalization).

Links to useful information that relate to Ab 1308, Medical Board Agenda 11-B (VBAC) and efforts to legally restrict access to VBAC services by making it illegal for licensed midwives to provide childbirth services to any woman who had previous Cesarean surgery

Part 1 –Overview of unintended consequences of AB 1308 –>

The medicalization of normal childbirth in healthy women with normal term pregnancies has become the ‘customary’ practice in the US even thought . It begins with the routine of continuous EFM as the universal standard of care, the ‘liberal’ use of Cesarean surgery and

Opinion #166 ~ “Informed Refusal” ~ notes:

Almost universally, informed consent laws have been liberalized … from the relatively paternalistic “professional or reasonable physician” standard to the “materiality of patient viewpoint” standard. … In the “patient viewpoint” standard, a physician must disclose … the risks and benefits that a reasonable person in the patient’s position would want to know in order to a make an “informed” decision.

Opinion 214: “Patient Autonomy: The Maternal-Fetal Relationship” states that:

• … medical knowledge has limitations and medical judgment is fallible. Existing methods for detection … are not always reliable indicators of poor outcome, and there is often insufficient evidence for risk-determination or risk-benefit evaluation
• The role of the obstetrician should be one of an informed educator and counselor, weighing risks and benefits ….and realizing that tests, judgment, and decisions are all fallible.
• Abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances.
• In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes regardless of the consequences.

ACOG Opinion 214 also identifies serious negative consequences when a patient’s autonomy is violated:

• A woman is wronged and may be harmed, whether physically, psychologically or spiritually.
• The patient’s subsequent loss of trust in the healthcare system may reduce the health care provider’s ability to help her and may deter others from seeking care.
• There may be other social costs associated with this violation of individual liberty.

According to ACOG Opinion 214: “abiding by the patient’s autonomous decision will provide the best care for the pregnant woman and the fetus in most circumstances”.

This policy statement goes on to say that: “In the event of an emergency … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes, regardless of the consequences.”

Citation ~ ACOG Committee Opinion # 214: ACOG Compendium p. 160 April 1999 no. 214

An HONORABLE PEACE . . . .^O^

Never forget: Our immediate goal for any legislation affecting healthy childbearing women and midwives is an “honest bill“. Our long-term goal is an “Honorable Peace” btw women (as mothers & midwives) and 21st-century obstetrics as a surgical specialty.

Learning to ‘Love the Bomb’ while working for an ‘Honorable Peace’ with obstetrical medicine

Unfortunately for midwives, becoming a legalized profession does not let us dispense with the thorny issues of mfry licensing or organized medicine’s eternal hostility towards PHB midwives and physiologic childbirth. These contentious issues will remain relevant, which means we must “persist”.

Eventually, we all — midwives, mothers, and obstetricians — will have to ‘learn to love the bomb‘, because none of us are going away  — not childbearing women, not midwives, not obstetrically-trained doctors. Come back in 10 or 20 or 30 years and there will still be childbearing women, midwives, and doctors. Occasional controversies will still occur, but my prayer is that 10 or 20 years from now, they won’t lead to the same threats of legal action against parents or professional midwives that have been the norm for more than a 100 years in many parts of the US.

“Normal” childbirth under obstetrics management from the mother’s perspective

But whatever the cost and inconvenience, we can’t continue to tolerate or live with a dysfunctional maternity system that simultaneously refuses to care for some childbearing women (many high risk who greatly need such care), while the system routinely performs medical treatments and surgical procedures on perfectly healthy childbearing women, even when they don’t want or need the interventions and have said “no!” several times.

The consequences of unwanted and medically-unnecessary interventions, as compounded by the hospital’s ‘defensive medicine’ protocols, is generally to the detriment (and often the regret) of the laboring woman.

Nonetheless, she persisted . . . .

We too must “stay the course” until the maternity care system in the United States no longer refuses to care for childbearing women seeking physiologically-based childbirth services or insists on performing medical treatments and procedures to women who don’t want, need or benefit from such non-consensual care. Sooner or later, we simply must end the Hundred Years War against normal childbearing and the experienced midwives who had been trained to attend normal births.

Like all the millions of other “laboring women” throughout time, (to be female is to be a laborer), we laboring midwives must stretch ourselves a centimeter at a time, while looking for ways that we each can personally further the action — no matter how small — toward an honorable peace btw midwifery and medicine.

A respected philosopher of centuries past defined morality with this brief, yet profound, statement: “No one may be harmed without their consent“.

We can’t stop our political efforts at rehabilitation until our dysfunctional maternity care system officially acknowledges the physiological management of normal labor and birth as the universal standard of care for healthy women with a normal pregnancy at term.

That means teaching the principles of physiologic childbirth in medical schools, employing experienced midwives to teach the hands-on skills to obstetrical residents during their clinical training, and that physicians will practice them after graduation as the science-based standard for healthy childbearing populations.

It also means staffing hospital L&D units with professional midwives for those occasions when obstetrical providers are not able to be physically present throughout the active labor, birth, and the first hour after the baby is born as the birth attendant is helping the mother breastfeed for the first time. Care by hospital-employed midwives would also apply when obstetricians simply choose not to “labor sit”.

However, birth attendants (of whatever background) that don’t “labor sit” also don’t get to ‘catch’.

As mothers and midwives, we learned the hard way (i.e. earned) the right to claim that much-cherished quality characterized in the media as “nonetheless, she persisted…“.

Eventually, both sides will figure out that the ‘nuclear option’ is not an option.  Mutual survival requires “civilized behavior”.

It behooves us NOT to name-call or ridicule anyone in public. Equally important,  we continuously seek out those areas of compatibility, where we, the human species (i.e. we ‘THE PEOPLE’) are already in agreement. This can happen in a tiny corner of time when we talk candidly to each other and walk away a little bit smarter, a tad more tolerant, a bit more understanding of the other person’s viewpoint, and able (mostly) to greatly lengthen the distance btw the spark and the match.

In this case, we consciously choose NOT to jump to conclusions or assume the very worst of the other side. And when our best intentions fail us (as they always do), we climb down off our high-horse, apologize, and do our best to fix whatever problem we have created for ourselves and others.

PHB of healthy mother as attended by Heather Demare Moll, California

MIDWIFE CALLING: I am personally asking Ca LMs to go the “extra mile” by reading an extraordinary paper on the ethics of informed consent and refusal of unwanted obstetrical intervention by maternity patients. It will allow you to quote knowledgeable, peer-reviewed sources when talking to Legislators and their office staff.

This very timely paper was written by a family practice physician that provides hospital-based maternity care in Yellowknife, BC, Canada and published this month in the journal BIRTH.

LINK to a PDF copy: Informed-Consnt&Refusal_Kotaska BIRTH 2017

Dr. Andrew Kolaska is obviously very familiar with ACOG’s Committee Opinions on informed refusal, as he uses both the language and impeccable theory from ACOG’s Committee Opinions #166 and #214. He uses ACOG’s own official policies as the foundation for factual statements and his recommendations.

Since there are so many papers and other documents on the topic of “informed Consent” and maternity care, and I found this one is so special, I have been referring to it as the “Yellowknife Paper“ to make it more memorable and be sure that it gets distributed as widely as possible.

Dr. Andrew Kolska is also a long-time contributor to the Canadian MCDG (a list-serv for family practice physicians who attend births & midwives. The Maternity Care Discussion Group has been moderated by midwife-friendly Dr. Michael Klein for 20-plus years. For those of us who read his MCDG posts, we think of him as ‘Andrew’ and are very grateful for the helpful information he so freely shares.

. . towards an honorable peace . . . .

1. Introduction & brief background of me and general ideas about these issues (7 mins):

[embedyt] https://www.youtube.com/watch?v=WhvvpdDKjGk[/embedyt]

2. Most relative to KillBill efforts of 2017 –>SB 457 (29 mins)

[embedyt] https://www.youtube.com/watch?v=991Ovq0pZGc[/embedyt]

3. About mfry licensing:

[embedyt] https://www.youtube.com/watch?v=Ue8HC3Sb9lE[/embedyt]

4. Kathi asks “How do we decriminalize?”

[embedyt] https://www.youtube.com/watch?v=CM1bHTvp8y8[/embedyt]

5. Professional mfry as a critical step towards integrative maternity care for healthy women with normal pregnancies, and relative to postpartum and neonatal care for new families

[embedyt] https://www.youtube.com/watch?v=EAeqsgdVJ38[/embedyt]

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

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 

Intro, Overview & Grand Vision:

Our Standard-of-Care is also our most public face

A standard of care is like a professional Constitution & Bill-of-Rights all rolled into one. As published online, this document is the single most important source of public information about the principles and professional practice midwifery available to childbearing families, journalists, reporters, legislators, attorneys and other interested parties.

As our public face, we need to be sure that any Standard-of-Care for CaLMs accurately reflects the principles of midwifery practice as a professional, evidence-based, 21st-century healthcare discipline, while functioning smoothly at the practice level for midwives and the childbearing families we serve.

By weaving together the traditional knowledge and practice of midwifery from multiple legacy resources with the most recent scientific advances, it possible create a custom standard of care for CaLMs that will help us preserve and protect the eternal verities of midwifery practice.

The CaLM Collaborative Work Group is a small volunteer work-group of Ca LMs with a passionate interest in a formal standard-of-care that reflects the community-based practice of midwifery in California. We represent ourselves as individual practitioners and we also reflect and represent the views and values of various midwifery-related groups and organizations.

We begin to meet regularly on May 23rd, 2015 and are currently teleconferencing weekly. We hope to finish the first draft in the next 90 days. We are using the California College of Midwives‘ Standard of Care (2004 version, updated 2015) as a placeholder and structural template. However, the final product will be a public document not associated with any particular midwifery organization, but rather an eclectic blend of the best contributions from all sources.

So in addition to our own personal opinions and perspectives, we are making use of the ‘institutional memory’ (i.e. traditional wisdom) provided by already published professional standards-of-care, practice guidelines, and evidence-based policies (see list of legacy documents at the end). These historical and contemporary documents are an excellent source of in-depth information and time-tested ways of expressing these important concepts. It also is a way to acknowledge that we stand on the shoulders of those who went before us and that we recognize the value of these traditions and are proud to carry them forward to future generations.

The purpose of a professional standard of care for CaLMs is to:

• function as a reliable source of updated information, practice guidance, and technical bulletins
• 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

The eventual goal is to produce a cohesive whole that will be informative to individual practitioners and the public at large, as well as providing legal guidance for the community-based practice of professional midwifery in the state of California.

The time-consuming background research on comparable Standards-of-Care has already been done, so thankfully our Collaborative Work Group does not have to re-invent the wheel. Instead, we are simply updating and tailoring CCM place-holder material to better serve CaLMs in the post-AB 1308 world. We are paying close attention the clarity of its language, economy of words, and the specific legal requirements of the LMPA (all 4 amendments, especially AB 1308).

For anyone familiar with either the long (52-page) 2004 CCM version or the short, 14-page version adopted by the MBC in 2006 as the SCCLM, these edits are relatively small and should not greatly affect the day-by-day practice of community-based midwifery.

However, we are also concerned about the geographical & political realities of practicing OOH midwifery a big state such as California and also the issues that are unique to any midwife with a very low-column practice, especially in remote or rural areas. Customary practices at the local can be very different in different communities. Much depends on the area’s healthcare resources, especially access (or lack of access) to physician consultation and emergency response services.

Obviously those are very different in a big metropolitan area such as LA county, San Diego, San Francisco-Oakland, and Sacramento, when compared to rural counties (Humboldt, Mendocino, etc), agricultural areas north of Sacramento and the Central Valley, and high desert communities in the area of Bakersfield, Lancaster, Palm Springs, etc.  One size obviously doesn’t fit all, hence the need for feedback from practicing midwives.

After we complete the first draft,  we will provide CaLMs with an online opportunity to read and provide feedback (questions, comments, suggestions, and requests!) As is appropriate, we will integrate the collective body of suggestions to produce a finished product that will update the “best of the best” to “even better”. This process may take as long as a year to complete, but we hope to offer a professional Standard-of-Care for the practice of professional, OOH midwifery in California.

Our hope is that CaLMs will voluntarily adopt the document either in toto or in part, such as group midwifery practices that identify specific portions as the standard-of-care for their individual practice.

It must be stressed that its use by any individual LM is strictly voluntary and that this is the normal relationship between all healthcare professions and the professional practice guidelines published by their various professional organizations. This even true for ACNM, ACOG, AAP, etc.

A big part of what makes us professionals in the ‘healing arts’ is that we voluntarily and publicly commit to adopt and abide by a published standard of care for our discipline. Legally a CaLM can create her own unique ‘version’ (which is available to her clients) or she chooses instead to inform her clients that she practices under the standards of care developed by her professional organization (CALM, California College of Midwives, etc) and them provided a copy or a link to the organization’s formal document.

You have finished Part 1 — to read part 2 click here

 References ~

Reference

Direct Link to
References

Professional midwifery organizations and state, national and international sources originally used in compiling the 2004 Standard-of-Care document and the shorter, 14-page document (SCCLM) adopted in 2006 by the MBC:

1. Alaska Statutes and Regulation – AS 08.64 and 12 AAC 14
2. Arizona Licensed Midwives Rulemaking – 8 AAR 2896, June 18, 2002
3. California Assoc. Midwives’ Certification, part3 – Regulation for the practice of midwifery, Standards, Duties and Responsibilities and Guidelines of Practice 1985, 1989
4. Central Midwives Board Handbook, Incorporating the Rules of CMB; UK, 25th edition, 1962
5. 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)
6. 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
7. Florida State Statutes for the Practice of Midwifery ~ Responsibilities of the Midwife
8. From Quackery to Quality Assurance – First 12 Decades of the Medical Board of California, 1995
9. Midwives Alliance of North America’s Core Competencies for Basic Midwifery Practice
10. Midwives Alliance of North America’s Standards of Practice, October 1997
11. New Hampshire Statutes for Professional Midwifery Practice
12. New Zealand Handbook For Practice, Code of Ethics, 2001
13. Office of Administrative Law ruling by California Judge Roman in August 1999 ~ Standards of Practice, Duties and Responsibilities acknowledged as appropriate for licensed midwives
14. Original  Statutory Requirements to Practice Midwifery 1917 to 1993 ~ for state certified (i.e. licensed) midwives under the regulatory authority of the California Medical Board
15. Principles of Midwifery Practice; Netherlands, Kloosterman (unsure of date but probably mid-1990s)
16. Standards for the Practice of Nurse-Midwifery; Philosophy, Ethics, Guidelines for Incorporating New Procedures into Nurse-Midwifery Practice, ACNM
17. Standards & Guidelines Professional Nursing Care of Women & Newborns, AWHONN 1998
18. Second Stage Labor Management; Promotion Evidence-Based Practice & Collaborative Approach to Patient Care, AWHONN, 2000
19. Tennessee Association of Midwives ~ Practice Guidelines, adopted January 2001
20. Texas Statutes for Direct-Entry Midwives
21. The Obstetrician’s Professional Liability – Awareness & Prevention; Dr. David S. Rubsamen, MD, LL.B 1993
22. Washington State Criteria ~ Pilot Project for Planned Home Birth
23. Washington State Standards for the Practice of Midwifery, December 2002