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In California, Nurse Midwives Deliver — But Still Answer To Doctors

By Sarah Torna Roberts

After an almost too easy road toward adoption, California Assembly Bill 1306 died on the Assembly floor in the last hours of the last day of the most recent legislative session. Had it passed, the state of California would have allowed certified nurse midwives (CNMs) to fully utilize their education and training without the archaic requirement of physician oversight — and women’s medical care in California would have finally entered the 21st century.

That is because CNMs are experts. They are registered nurses with master’s degrees of science with a specialty in nurse midwifery. They are trained in providing women with excellent care from puberty to menopause, with an emphasis on pregnancy and birth in normal, healthy women.

So physician oversight is a requirement that serves more as bureaucratic red tape than actual protection for a patient. Part of that is because the definition of “oversight” remains vague, and the term has been interpreted in various ways by different entities. In most cases, CNMs are providing care directly to patients without the physical presence of a medical doctor, and “physician oversight” amounts to little more than a doctor who is technically held liable for the actions of that CNM. The overseeing physicians do not have to be in the room when care is being provided. They don’t even have to be on the premises. Even in the hospitals, the physicians aren’t looking over the shoulders of the CNMs as their patients give birth.

This is one distinction often misunderstood by those who hear the word midwife and assume a correlation with home birth. Actually, 95% of CNMs attend births in the hospital, not at home, and they care for women who are experiencing low-risk, normal pregnancies. Because this is the scope of their practice, they take seriously their responsibility to collaborate closely with OB/GYNs, especially regarding any patient who would benefit from a different type of care.

“Obstetricians and gynecologists are trained surgeons whose skills should be utilized for patients in dire need of intervention — not normal, healthy women,” stated Melissa Wilmarth, a recent graduate of Georgetown University’s nurse-midwifery program who moved her family to Visalia, California, to provide care to a community that has limited numbers of practicing CNMs.

Currently in California, there are only 2.44 OB/GYNs for every 10,000 women, so allowing CNMs to practice within their full scope would leave OB/GYNs free to tend to the patients who really need them. Had AB 1306 passed, the unnecessarily long patient lists of OB/GYNs could have been reduced, no doubt increasing the quality of care all women receive.

But instead of welcoming this monumental advancement of better quality health care for women, as well as increased access for women of all socioeconomic levels and geographic locations, the California Medical Association (CMA), a professional organization made up of California doctors, fought tooth and nail to keep this bill from passing into law. In their perspective, if CNMs became autonomous in the eyes of the law, physicians would experience competition for the first time — an end these doctors were unwilling to accept.

According to Rebecca Garrett-Brown, California Nurse-Midwives Association’s president-elect, the CMA had nearly a dozen lobbyists on the floor of the California state assembly during those final important hours, all of them insisting that passage of AB 1306 would leave patients unprotected in the hospital setting, a claim that Garrett-Brown says is “just not true.”

The CMA-hired lobbyists were, however vaguely, referring to the corporate practice of medicine that assembly member and author of AB 1306 Autumn Burke removed from the bill in order to acquire support from the California Hospital Association prior to the final vote.

The corporate practice of medicine ban is a state doctrine that bars corporations, including hospitals, from directly hiring physicians and CNMs. The ban was originally intended to protect patients from the possible abuses a corporate entity can inflict if a physician or midwife ultimately answers to the corporation’s interests over the patient’s needs. But doctors have been worming their way around this law for years by joining together and presenting themselves for hire by a hospital as a “medical group,” not as individual physicians. And most other states have done away with the CPM ban in favor of other measures to protect the integrity of medical care, citing the antiquated language of the ban in light of the many exceptions and loopholes (ahem, those “medical groups”) already employed.

But California has refused to budge, interpreting the CPM ban as stringently as possible and also allowing powerful groups like the California Medical Association to use it as a scapegoat for their opposition to lifting the physician oversight requirement on skilled medical providers like CNMs.

When state representative Burke removed the CPM language from AB 1306, other language was added to support the intent of the ban. California Nurse-Midwives Association health policy chair Kim Dau stated, “Nurse midwives are on board with the concept of the ban on the CPM. We want to completely avoid conflicts of interest in patient care. Period. What we object to is how it is used to define the terms of our relationships to our employment, thus limiting access.”

To that end, AB 1306 was amended to read, “the bill would prohibit entities described in those specified settings from interfering with, controlling, or otherwise directing the professional judgment of such a certified nurse-midwife, as specified.” In light of this amendment, one would think the CMA would lift their objections, but they did not.

At this point, one must ask why a state known for its progressive ways is allowing the CMA to keep women’s access to medical care in the dark ages.

In the opinion of Linda Walsh, CNM and outgoing president of the CNMA, it’s all about the financial power of the CMA, the physicians’ professional organization. For years she has watched the CMA wield its power often in direct contrast with the will of the people. “Follow the money,” she said, noting that the CMA has given not insignificant amounts of money to various California senators and assembly members. “My own senator, Bill Monning, has never voted for a bill CMA opposed, even when his constituents have heavily supported the bill and shared that with him (as with AB 1306).”

Despite the fierce opposition of the CMA, Walsh says that the physicians she has worked with have always fully supported nurse-midwifery, but added, “That being said, I’m not sure how many felt safe enough to be vocal about support of the bill.”

Garrett-Brown has also enjoyed tremendous support from the physicians with whom she has collaborated with at University of California, San Diego for more than 20 years, naming Dr. Thomas Moore and Dr. Yvette LeCoursiere specifically. She stated that, contrary to Walsh’s experience, both physicians actively support midwives engaging in their full scope of practice and wrote letters on behalf of AB 1306 to share this perspective with the legislature.

In fact, physicians and nurse-midwives have long enjoyed a collaborative and mutually beneficial relationship, one that has been widely acknowledged on a national level. The American Congress of Obstetrics and Gynecology has put out several very strong position papers identifying nurse-midwifery as independent and autonomous. However, the CMA continues to insist that the relationship be hierarchical rather than collaborative, if only in law.

“For us, it’s all about access,” stated Garrett-Brown, who noted that California currently has nine counties that do not have OB/GYN care of any kind. With the passage of AB 1306, CNMs would have been free to establish practices and free-standing birth centers in some of these areas, increasing the number of providers available and the number of women with access to medical care.

Wilmarth, the recent graduate from Georgetown’s nurse-midwifery program who just passed her nationally accredited boards examination, will join an obstetrics practice alongside one other CNM. She’s thankful for a job with physicians who are supportive of her role in the practice, but she’s very aware that many newly-graduated CNMs in California are either forced to move to a more midwifery-friendly state or must continue to work as an RN until a CNM job opens up.

When Walsh moved to California from the east coast in 1990, she routinely asked her colleagues why California didn’t have more established midwifery practices. She says the answers were always the same: “powerful physician groups who didn’t want the competition, plus a declining birth rate.”

Considering the outcome of AB 1306, it’s not difficult to acknowledge the power of the CMA and the power of the almighty dollar. Unfortunately, what they are paying for isn’t better patient protection and care, which is the excuse they’d have you believe, but the autonomy of qualified medical personnel able to provide excellent care to thousands of women who deserve exactly that.


Lead image: flickr/usarmyafrica