Oregon dramatically tightens homebirth coverage requirements

Homebirth insurance claim

In a tremendous victory for the mother and babies of Oregon, and a tremendous repudiation of homebirth midwives, Oregon has dramatically tightened the requirements for coverage of homebirth.

In many ways, homebirth midwives led by Melissa Cheyney, brought this on themselves. Their utter contempt for safety requirements of any kind led to their marginalization. Four years ago they were dragging their feet on even obtaining consent for homebirth, now it has been entirely removed from their hands.

Here is the document that sets out the new coverage regulations Health Evidence Review Commission (HERC) Coverage Guidance: Planned Out-of-Hospital Birth.

Oregon Medicaid won’t pay for homebirth of breech, twins, VBAC, prolonged rupture of membranes and other conditions that homebirth midwives pretend are “variations of normal.”

It is a 100 page review that carefully documents the conclusion that homebirth is only appropriate in a restricted set of circumstances.

As a result, Oregon Medicaid will no longer pay for homebirth in the case of breech, twins, VBAC, prolonged rupture of membranes and a whole host of other conditions that homebirth midwives chose to pretend were “variations of normal.”

Why won’t Oregon Medicaid pay for homebirth in those circumstances? Because they dramatically increase the risk of perinatal death. Judith Rooks CNM MPH analyzed the 2012 Oregon homebirth statistics  and found that the death rate at planned homebirth with a licensed homebirth midwife was 800% higher than comparable risk hospital birth. Moreover, 6 of the 8 deaths in the homebirth group occurred in women that did not meet the criteria for low risk.

What is especially interesting about the HERC document is that it details an extensive review of the literature … a real review, not the cherry picking of papers and misrepresentation of findings that characterize homebirth advocates’ review of the literature.

The authors also call into question the validity of assessing homebirth safety in the US by citing studies from other countries. The note the differences in midwifery training:

The Netherlands

“The midwifery training is a four year fulltime direct entry education, which eventually leads to a Bachelor’s degree. The total study load is 240 ECTS and equals nearly 6,800 hours of education. Altogether, there are two years of theory, one year of primary care internships, and one year of secondary and tertiary care internships. The internships are spread equally over these four years… They have had an extensive assessment, which selects the best candidates. Around
three times more candidates apply for the course than places are available.”

Canada

British Columbia
“All current CMBC approved programs are Canadian four year direct‐entry education programs leading
to a university degree, or bridging programs leading to equivalency.”

Ontario
“1. The applicant must have at least one of the following:
A baccalaureate degree in health sciences (midwifery) from a university in Ontario.

2. The applicant must:
Have current clinical experience consisting of active practice for at least two years out of the
four years immediately before the date of the application, and
Have attended at least 60 births, of which at least:

  • 40 were attended as primary midwife
  • 30 were attended as part of the care provided to a woman in accordance with the
    principles of continuity of care
  • 10 were attended in hospital, of which at least five were attended as primary midwife,
    and
  • 10 were attended in a residence or remote clinic or remote birth centre, of which at
    least five were attended as primary midwife

3. The applicant must have successfully completed the qualifying examination that was set or approved
by the Registration Committee at the time the applicant took the examination.”

As compared to:

North American Registry of Midwives [CPM certification]

There are multiple routes to certification by the NARM, but in general they include a written test, a skills
assessment test, and the following experience requirements:

  • Phase 1: Births as an Observer
    Ten births in any setting, in any capacity
  • Phase 2: Clinicals as Assistant under Supervision
    Twenty births, 25 prenatal exams, 20 newborn exams, 10 postpartum visits
  • Phase 3: Clinicals as Primary under Supervision
    Twenty births, 75 prenatal visits, 20 newborn exams, and 40 postpartum exams

There are other difference as well:

Good outcomes for planned out-of-hospital birth have been demonstrated in several countries. However, these settings have system characteristics that help to maximize safety. Chief among these is a robust system of consultation and referral/transfer that can assure seamless care for the woman and her newborn when transfer is needed. In addition, these systems include thorough education (informed consent) of women and families about the potential need for consultation/referral/transfer and the potential risks associated with having a delay to receipt of emergency obstetric and neonatal care.

Consideration of distance and time from a hospital able to provide emergency obstetric and neonatal services is important in managing intrapartum complications and in providing fully informed consent. Another characteristic is written agreements that cover consultation/referral/transfer and a welldefined and practiced system of transfer. Out-of-hospital birth attendants in these systems are appropriately trained and experienced in the identification and management of obstetric and neonatal emergencies, and are also licensed and certified. These providers should be capable of initiating appropriate newborn resuscitation, and be able to provide standard newborn care in addition to the routine postpartum care of women. Certification requirements for the practice of midwifery can vary significantly between the U.S. and other countries, with U.S. requirements for midwives, other than CNM/CMs, generally being less rigorous with regard to both years of formal education and experience.

These new restrictions are just the first shot across the bow. Even NARM and MANA can see the handwriting on the wall: the CPM certification is going to be phased out. As a result, they have created the Midwifery Bridge Certificate.

NARM is planning for the day when the CPM certification will no longer be enough:

Opposition to the licensure of CPMs has centered on the lack of a requirement for an accredited education. Work among the seven US MERA organizations in 2015 created a joint statement of support for licensure legislation on the condition that it include a requirement for a graduation from a MEAC accredited program or the Midwifery Bridge Certificate.

Both the HERC regulations and the NARM Bridge Certificate represent an extraordinary victory for homebirth safety and a tremendous vindication for those who have been arguing for years that American homebirth midwifery is both substandard and unsafe.

We have been heard!

  • DoulaGuest

    “Both the HERC regulations and the NARM Bridge Certificate represent an extraordinary victory for homebirth safety and a tremendous vindication for those who have been arguing for years that American homebirth midwifery is both substandard and unsafe.”

    I’m sorry but, what??? An extraordinary victory? You have got to be kidding me! The bridge program is a JOKE! It does absolutely nothing to give CPMs the critical thinking or skill sets needed to become safer providers. It’s lip service, and nothing more. 50CEUs of emergency training and you can say you meet ICM standards, which most of them don’t think means anything anyways. I am beyond disappointed that this is your viewpoint.

    • Eugene Mom

      If you think this isn’t a victory, then you have NO IDEA how bad it is has been here in Oregon. The key to this is not the bridge program, which is an utter joke, but is the removal of easy Medicaid (OHP) funds for HB.

      I cannot even explain the impact this is having, as well over half of all moms are on OHP, and the insurers will be following suit. At best, it shuts down reckless BC’s (a horrible one closed about a week after this!), and worst, it makes HB moms either get actual testing and care, or pay out of pocket. I guarantee it will save lives and brain cells.

  • Eugene Mom

    This is the end result of a small, but extremely dedicated group of woman, some health care providers, OBs, CNMs, nurses, loss moms, and others that care about HB safety.
    They worked hard, attended countless meetings, dealt with idiots and politicians, but did manage to make this happen. I wish you all knew the huge amount of effort that went into this.
    Let’s thank them. This will spread to other states, and protect many moms and babies.

  • CharlotteB

    Couple questions I’ve been pondering: 1. I should probably read the document again, but I didn’t see anything about maternal age, either as an automatic risk-out or for OB consultation. 2. Have any of the big pro-CPM groups (MANA, et al) have made any comments about this? And 3. In reference to #2, I’m guessing they can’t–I’m assuming that most or all of these risk-out criteria are the same ones used in the UK and Netherlands. If true, then it really takes the wind out of their sails.

    • Bombshellrisa

      Melissa Cheyney will be discussing the MANA stats at the midwives association of Washington conference on Friday, one of the things being discussed is “older than average age” mothers and if that is a risk and how it reflected in the MANA stats. It is available as a webcast, I won’t be watching but if anyone here is, I hope they will post what they learned.

    • PInky

      In the uk it is the mother’s decision where she gives birth, which may be at home against advice, but always her decision. Midwives have a legal duty of care to attend whether they like it or not. All the risk factors included in the Oregon list plus maternal age, diabetes, bmi would also be included, but a woman cannot be denied a home birth by anyone.

      • Who?

        In real life I suppose that’s always true. If you refuse to stir, you end up with a home birth; if you refuse a transfer when the ambulance comes, you get a home birth. Though maybe then the paramedics will stay and help if you don’t toss them out, and let them help.

        Having the insurance not paying for dodgy midwives just means they are less likely to be involved. If mother wants to go it alone, there is nothing to stop her. Given the nonsense some of these midwives indulge themselves in it’s hard to imagine alone would always be less safe.

      • fiftyfifty1

        No, they can’t be denied, but they can be repeatedly highly discouraged. That counts for a lot and will dissuade the majority of mothers. And can bet your bottom dollar (or pound) that they will be omitted from studies such as the Birthplace study that were designed to show that homebirth is safe.

      • Azuran

        But at least their midwives are real midwives, with proper training and knowledge, professional standard of practice and are held accountable for what they preach.

  • Dr Kitty

    I hope someone somewhere is planning to collect the data and compare outcomes for the following groups:

    Genuinely low risk HB
    Risk-outs who transfer to hospital care
    Risk-outs who self fund HB
    Risk-outs who “UC” (in which case MW might be a “doula” or “friend” who takes payment in gold or chickens or yard work or something else one doesn’t have to declare to the IRS).

    I suspect it will make interesting reading, and the “as safe or safer” line might finally disappear.

  • areawomanpdx

    Christmas came early this year for sure. Takes effect 1/1/16/

    Also:

    “An ultrasound is required to rule out certain risk criteria (e.g. multiple gestation, placenta previa, and life threatening congenital anomalies). Certain risk criteria require serial measurements such as fundal height and blood pressure.

    If a woman refuses a required clinical or diagnostic assessment, then ascertainment of her risk status is unknowable and she does not meet criteria for coverage for an out-of-hospital birth.”

    http://www.oregon.gov/oha/herc/GuidelineChanges/Prioritized-list-Planned-out-of-hospital%20birth.pdf

    • areawomanpdx

      “Documentation of continuing appropriate risk assessment and routine prenatal care is required.”

    • Dr Kitty

      Excellent.
      No more surprise multiples and some chance IUGR, pre-eclampsia and GDM might be picked up and appropriately managed.

      • yugaya

        Also:

        – GBS+ and decline abx = not covered
        – unknown GBS status = risk out to hospital or not covered
        – refuse STD test = not covered
        – post term = risk out to hospital or not covered

        NO IFS. NO BUTS. NO VARIATIONS OF NORMAL.

        I believe that this Oregon legislation has everything of importance – covered.

        • The Bofa on the Sofa

          And the most important thing about it is, how can the midwives complain? They keep saying how homebirth is acceptable in the right circumstances, so how can they claim it applies to unknown status?

          • Megan

            Yup. Complaining would require that they admit that their real motive is income and lack of oversight.

          • The Bofa on the Sofa

            “It’s unfair! We won’t be able to do homebirths with high risk patients!”

          • Amazed

            It’ll be about CHOICE again. They’ve long been saying that they exist to serve the woman’s CHOICE, no matter how dangerous it is. One of the reasons they claim for opposing any oversight is that high risk women will just go on their own which is more dangerous (I know, I know it’s BS. Give me a level-headed taxi driver over a midwife passionate to save me any day of the week.)

          • yugaya

            No one is banning high risk homebirths. Even the midwives are free to attend them all they want in the absence of state regulation. This is about hey you want to go AMA and have a high risk homebirth? No problem, but you will pay that shitty, reckless homebirth midwife of yours out of your own pocket.

          • Amazed

            Hey, I found something about you that I didn’t know! You’re a softie! You really think they’ll put up with this? When they whined about all the paperwork they had to do in order to be reimbursed by Medicaid?

            Ah yugaya! Thinking the best of people. I thought you have become cynical around here.

          • yugaya

            I have zero problem with choices to go against medical advice and have a high risk homebirth, as long as those choices are acknowledged as deadlier and under no circumstances to be “as safe or safer than a hospital birth” and following guidelines.

            From the samples I’ve seen of how fake midwives *keep records*, sth like 90% of them will be kicked off Medicaid reimbursements during the initial period. Filing coded insurance claims was too hard for the most – imagine their horror now when the actual medical documentation will be required.

          • Susan

            Yeah, what fun will it be with all this normal stuff?

        • MaineJen

          Also, no non-cephalic presentations allowed. Boo-yah!

    • The Bofa on the Sofa

      If a woman refuses a required clinical or diagnostic assessment, then ascertainment of her risk status is unknowable and she does not meet criteria for coverage for an out-of-hospital birth.”

      DROP THE HAMMER!!!!!

      This is a significant line. You can’t close your eyes and then claim “I didn’t know”

    • Megan

      That is fantastic. My guess is CPM’s won’t want to bother with all that documenting and honesty and will just stop doing deliveries for insured patients (unless they opt to pay OOP of course). This is a big win for the safety of mothers and babies in Oregon.

  • Daleth

    Slightly OT, but look: even this “traditional birth attendant” in northern Nigeria wears rubber gloves, which is more than can be said of some American CPMs (4th photo down):

    http://www.slate.com/blogs/behold/2015/11/17/mark_tuschman_photographs_women_and_girls_in_the_developing_world_in_his.html

    • Roadstergal

      “In a clinic outside of Dhaka, Bangladesh, a nurse attends a teenage mother’s baby. The young mother, 15, is in the background, very detached from her newborn infant.”

      Fucking hells yes, I’d be detached if I had been forced to have a baby at 15!

      Contrast that with the engaged and excited girls around the laptop, and the quiet, satisfied look on the face of the girl with the school bell…

      • demodocus

        And heaven knows the circumstances the 15 year old *got* pregnant. Maybe it was enjoying time with her boyfriend, but somehow, I think it’s unlikely.

        • Dr Kitty

          Oh no, married at 14 I’d guess.
          Child marriage isn’t legal in India, but during my medical school elective in a rural Indian hospital we did a tubal ligation on a 16 year old married mother of three, who happened to be our driver’s daughter. The doctors hadn’t been able to persuade him not to marry her off, but they had persuaded him to convince her husband that two sons and a daughter was enough.

          The high infant mortality rates manifests in some coping strategies that can look very odd. Newborns are dressed in rags and not given names for several weeks, nobody makes too much of a fuss of the new baby in case it draws bad luck and so on.

          I can’t imagine things would be too different in Bangladesh. Detachment might be a coping strategy for that girl.

          • demodocus

            doubtless, poor kid.

  • Michelle

    “Judith Rooks CNM MPH analyzed the 2012 Oregon homebirth statistics and found that the death rate at planned homebirth with a licensed homebirth midwife was 800% higher than comparable risk hospital birth. Moreover, 6 of the 8 deaths in the homebirth group occurred in women that did not meet the criteria for low risk.”

    I’m not sure I understand. Are you saying that the death rate for high-risk homebirth is 800% higher than the death rate for high-risk hospital birth?

    • MaineJen

      The material point is that Oregon homebirth midwives are ignoring their own risking-out criteria (if they have such criteria to begin with), and it’s resulted in a horrific death rate for babies who were “supposed” to be low risk.

      • Michelle

        Right, but I got the impression that high-risk homebirth was being compared to low-risk hospital birth, which isn’t a fair comparison. Or maybe it’s that the 2 low-risk homebirth deaths were being compared to low-risk hospital birth? I’d appreciate clarification.

        • Amazed

          Not a fair comparison? To whom? You really think that taking someone to their word, in this case “We only take low-risk women!” is unfair to this person? This huge group of people, in this case?

          What’s fair to women and babies, Michelle? What’s fair to them? When they’re lied to that midwives only take low-risk, some of them BECOME those extra deaths?

          Ok, let’s so it this way: Midwives say they only take low-risk women, so if you choose them, you believe you’re low risk. But in fact, their deaths happen prevalently with high-risk pregnancies that they swear they don’t take. Does that sound fair enough to you?

          Homebirth midwives claim that there is NO high risk women giving birth with them to be compared to high risk women in hospitals. Unfair to take them to their word? I thought that was called treating someone like a grown-up.

          • Michelle

            Whoa, chill. I just want to know if it’s high-risk or low-risk births that are 800% deadlier out-of-hospital. That’s all. I’m still not clear, even after I followed the link above.

          • Amazed

            If you just want to know this, then I’m sorry. I am just fed up with seeing the word “fair” in this type of posts. Usually, it goes with “Homebirth is safe for low-risk women but it isn’t fair to compare it to only low-risk hospital birth because it includes high-risk.”

          • Michelle

            Okay, I’m sorry. I didn’t realize this has already been hashed out here before. I’m not pro-homebirth, I just wanted to make sure that the comparison between homebirth and hospital birth is accurate, and, if so, if it’s comparing low-risk, high-risk, or all-risk.

    • Roadstergal
    • yugaya

      No. Quack midwives claim that they only attend low-enough risk births. They don’t. Rooks compared same class of risks intrapartum deaths OOH and in hospital, which means that the same type of high risk birth intrapartum deaths that midwives labeled “variation of normal” ( low risk) were included in the hospital group too.

      I can’t see what is unclear about any of what you quoted.

      • Amazed

        She also removed the death of a baby with congenital anomalies from the homebirth group but not the hospital birth group. I can’t remember her reasoning for this one.

        Even then, the results were telling.

        • Mer

          I think that one was intentionally born at home as a kind of hospice care and that’s why she removed it. I might be misremembering though.

          • Amazed

            Thanks!

  • Bombshellrisa

    Slightly OT: MAWS fall conference is this weekend in Seattle. http://www.washingtonmidwives.org/news-events/fall2015conference.html
    The MANA stats will be discussed by none other than Melissa Cheyney
    “Navigating Relative Risk at Home and in Birth Centers: Waterbirth, HBAC, Elevated BMI and Older Than Average Clients in the MANA Statistics 2.0 and 4.0 Cohorts”
    Melissa Cheyney, PhD, CPM, LDM
    Other than water birth, I thought all the above mentioned risk factors would risk a woman out of CPM care.

    • yugaya

      Oh great! Will Cheyney also explain where did they lose 25 women in their HBAC paper and how MANA 2.0 HBAC cohort magically went down from 1052 to 1027 from one table to the next ( quite conveniently in the only table in that entire paper with full disclosure of uterine ruptures)?

      • The Computer Ate My Nym

        Check out the neonatal outcomes for TOLAC with no history of vaginal birth. The combined intrapartum and neonatal death was 9.7 per 1000. In short, they managed to kill nearly 1% of healthy term babies. Who thinks this is a good idea?

      • Bombshellrisa

        The conference counts as 8 CEUs.

        • manabanana

          Some of which could be used for the BRIDGE CERTIFICATE through NARM. Perfect!

          • Bombshellrisa

            Exactly. This is the quality of “education” that can count toward the bridge program. I am not impressed.

  • Brooke

    Actually…you’re quite wrong about the education of midwives in the US http://www.midwife.org/The-Credential-CNM-and-CM . Something is also missing in your linked data because according to the CDC the infant mortality rate is 5.33%. That includes both hospital and homebirths with the vast majority of births occurring in a hospital setting. Its also seems misleading to say its several times risker to have a birth at home when you’re looking at less than 1% of births occurring at home with attendants of various levels of experience versus hospital births that represent 99% of births in which only a certified nurse midwife or doctor can oversee the birth.

    • Montserrat Blanco

      5.3%?????? Where is this data from? Worse than Rwanda???

      Most of the infant mortality in hospitals is due to prematurity or malformations. A baby born at 27-28 weeks has a 10% mortality chance with the best possible care. With a 10% of babies born prematurely (roughly), I do not have the exact number for the USA, if you compare babies born at hospital with babies born at home (presumably singletons, presumably at term) you are simply not comparing the same thing.

      Judith Rooks, a CNM did this comparison in Oregon and she found a significant increase in neonatal mortality in the homebirth setting.

      https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

      • Brooke
        • yugaya

          Infant mortality is not a measure of obstetric care. Perinatal mortality and especially Intrapartum fetal deaths at term represent the real measure of how bad OOH births attended by fake midwives are. Babies do not die like that in hospitals too – 0.1-0.3 per 1000 is the official estimate on number of such fetal deaths in hospitals.

          In Rooks 2012 report that was linked for you in previous comment, in Oregon intrapartum term hospital death rate was 0.6 per 1000
          With a fake midwife at home it was 4.8.

          Try harder.

          • Amazed

            What’s wrong with our visitors anyway? You – that’s generic you – will call when we have a homebirth advocate here who starts out knowing that Infant. Mortality. Is. NOT. The. Correct. Measure, right? Riiiight? I’d really want to see that.

            Seriously, it’s embarrassing how NO ONE of those who fly in to school us on stats is aware of this not so small detail.

          • KarenJJ

            Right. Doesn’t know the difference between CPM and CNM/CM. Doesn’t know what infant mortality is measuring. Tries to promote using absolute risk for decision making between two options over their relative risks…

            Brooke needs to do a bit more reading.

          • mythsayer

            And Brooke is gone. Because it’s embarrassing to find out you’re so wrong. If she comes back, I’ll be shocked.

          • Amazed

            She’s here. Lecturing us on morals in the birthzillas post.

          • yugaya

            Niiiiice.

        • Dr Kitty

          Infant mortality is all causes of death up to age one.
          That includes accidents and homicide.

          Are you are that the USA has much higher rates of both than most other developed nations?

          Causes are complex, but can be summed up as cars, guns, drugs, poverty and inequality.

          Unless CPMs have a magic wand that will prevent infants being killed when the meth lab in the basement explodes?

          • Brooke

            Lol no more like it’s because we have a for profit healthcare system.

    • KarenJJ

      That link on midwife education is for CNM and CM – NOT for CPMs.

      • Brooke

        The counter examples are for CNMs or their equivalents.

        • KarenJJ

          I don’t understand what your point is with posting the link for CNM and CM education and what you think Dr Amy got wrong. Can you explain further?

    • moto_librarian

      Repeat after me: perinatal mortality is the appropriate measure of obstetric care. Infant mortality is the appropriate measure for pediatric care.

      Thanks for playing.

    • mythsayer

      Various levels of experience? So you admit there are inexperienced attendants at home and that the hospital should have better emergency care right? So that would explain why PERINATAL mortality rates (not infant mortality) are better at the hospital than at home, as someone below explained, right?

      You can’t include congenital defects in either homebirth or hospital birth as they skew the stats. You need to look at comparable situations -low risk moms in both settings. Then you find .3 to 1.3/1000 at the hospital and at least 2.0-4.0/1000 at home. It may look like a tiny difference but when you consider it in tens of thousands…its 20 to 40 more dead babies who likely wouldn’t have died in the hospital. How do we know? BECAUSE THE HISPITALS HAVE LOWER PERINATAL MORTALITY RATES. SOMETHING is causing low risk moms to lose babies at a higher rate at home.

      WHY IS THAT, DO YOU THINK?

  • Nick Sanders

    Did disqus spend a few hours refusing to load for anyone else?

    • Sue

      Either nope (for me) or yes for all those out there who have not yet replied to your question 😉

    • Bombshellrisa

      Yes, I thought it was just me!

    • KarenJJ

      Yep but I thought it was due to my trying via my phone.

    • Amazed

      Nope (for me).

    • Megan

      I couldn’t get it to load at all last night, which was a shame as I noticed on the sidebar a really charming troll on the old MANA stats post calling people the “C” word. Trolls just love that word, don’t they?

  • Gatita

    http://www.mailtribune.com/article/20151103/NEWS/151109857

    Colebrook, who once had the distinction of operating the only two free-standing birth centers between Eugene and Sacramento, said it’s no longer feasible for her to run both. She cites the Oregon Health Plan’s (OHP) reimbursement process and the Oregon Health Evidence Review Commission’s (HERC) stringent guidelines governing midwifery as primary reasons.

    “As the OHP medical review board reviews each of our OHP client’s charts they have seen fit to deny payment for almost half of the women in our care,” Colebrook said.

    • EllenL

      See? It’s already working!! Hurrah!

      • yugaya

        They don’t get it that the real problem to begin with is that half of their clients are high risk and should not be encouraged or groomed by these fakesters to ignore the risks of OOH birth.

        • Amazed

          “The whole birth experience is really profound,” said Colebrook. “A lot
          of people think of birth as just another hospital procedure, but it’s
          actually a rite of passage in our life cycle. The way we do it here is
          informed both by the art and by the science.”

          Notice how art takes priority. Cute, eh?

          • The Bofa on the Sofa

            But see, it’s the great old fraternity (or sorority, as it were). It’s a “rite of passage” into the club! You aren’t a Real Parent (TM) unless you have the proper birth experience (make no mistake, this is not about the babies, so it’s not their “rite of passage.”)

            Personally, I do consider it very profound. At one point, there is not a baby, and then, there is a baby. At one point, you are not a parent, then, you are. “Having a baby” was as remarkable experience as there was. But it had nothing to do with hospital or how that baby arrived, it was about “having a baby” that was transformational.

          • Angharad

            She’s set up a nice straw man by saying people think of birth as “just another hospital procedure”. Which people? Is she implying doctors just don’t care about their patients and see them as statistics? Or that misguided women see giving birth as emotionally equivalent to getting a blood draw? I’ve never met anyone who doesn’t acknowledge that giving birth is a big deal and that parenthood is a big deal.

          • The Bofa on the Sofa

            Go to a hospital, and you will see the world of difference between the birthing unit and the rest. The rest of the hospital, to me, is very depressing. Then again, it’s filled up with people who are very sick or injured, feeling miserable and/or in lots of pain. People coming to visit them are coming with care, compassion and symathies to their plight. People in the other parts of the hospital get “get-well soon” cards.

            In the birthing unit, it’s very upbeat, patients are happy (even if they don’t feel well), visitors are joyous. They bring balloons that say “Congratulations.” No one brings “congratulations” balloons to the patient that just had their gall bladder removed.

            “Just another hospital procedure”? In what universe?

          • Lawyer Jane

            So true. I have had the misfortune of having to go to the hospital, let’s see, eight or nine times this year, for myself and other relatives. Every time I walked in the door I wished like hell it could have been for having s baby instead of what I was actually there for …

          • Amazed

            In the universe where the exact number of homebirths is cited as if the fact that there are so many is a wonderful things and the number of dead and disabled babies is… Wait, what? Dead and disabled babies do NOT exist in this universe. Let’s bury them twice!

    • yugaya

      Yessssss!

    • Sue

      Yay for standards!

  • sony2282

    I’m a little worried that this will lead to more CPM’s changing due dates, not doing GDM testing, fudging vital signs and symptoms so that their customers won’t risk out….notice i said customer and not patient.
    But overall this is amazing news! Does anyone have a name of a congressman or other official who voted yes on this that we can inundate with thank yous!? I want them to know we appreciate this step to protect mothers and babies!

    • Gatita

      They will try that but I’m sure Medicaid will follow up on the cases that go sideways and refuse to pay the claims if the risk criteria weren’t followed, plus they can ban providers from the Medicaid program.

    • EllenL

      That was my first reaction, too, the fudging issue. But I think it will be hard for them to do that. For one thing they will have to keep detailed records, and submit paperwork in order to be reimbursed. There’s going to be a lot more oversight than CPMS are used to.

      This is all to the good. Lives will be saved due to these new regulations.
      The more I think about it, the happier I am.

    • CharlotteB

      I was just thinking though–there’s probably a fair number of women who start to look for a provider, find out a homebirth/birth center is covered by their insurance, and think “oh, hey, that sounds nice! I’ll do that!” Then they get sucked in. Those same women, though, when they find out their insurance won’t cover a homebirth or that there is such strict risk-out criteria that they are probably going to shrug their shoulders and then be mostly happy with their hospital birth. If they’re super crunchy, maybe they’ll see a CNM and hire a doula.

      I do base this on myself–I wasn’t super crunchy but most of my friends had himrbirths, but I didn’t want a homebirth because of 1. We rent, we have pets, etc 2. I figured insurance would be easier with a hospital birth and found out the only midwives covered were CNMs at a hospital, and 3. I thought that transferring sounded scary and I preferred to plant myself and not have to worry about moving. None of it was based on safety because I assumed the risks were the same either way. I’d guess a lot of newly-pregnant women have the same mindset–yeah homebirth, candles, whatever, sounds nice, but if it’s not an easy or straightforward option they won’t take it.

      The more militant home birth types probably lean that way anyway, and insurance reimbursement/risk out is less of an issue.

      • KeeperOfTheBooks

        What you describe was true in my case. I wanted a homebirth. However, my insurance wouldn’t pay a dime towards one. It would, however, cover all but $30 (nope, didn’t leave off a zero, $30) of my prenatal care, DD’s birth, subsequent hospitalization for both of us, and postpartum followups. As a result, I went with a very NCB-friendly OB. Ended up with a CS anyway, but that was for DD deciding that All The Cool Babies Turn Breech, and neither he nor I, deep into the woo as I was, being willing to try a breech vaginal birth with an untried pelvis.
        I did look briefly into a couple of local birth centers staffed by CPMs which I think may have been covered by my insurance–not sure, though. However, one was 2+ hours away, and the other had reviews that ranged from disgusting (a midwife cooking FISH in an adjoining room to a laboring woman) to scary, even to woo-ish me (midwives leaving laboring moms alone in the building for hours). Nopity nopity nope nope nope.

        • Megan

          Wow. I want your insurance!
          And I went with my family doc for delivery since she does OB but my baby decided that All The Cool Babies Turn OP And Asynclitic and I got a CS too. Maybe we can just condense it to “All The Cool Babies Turn The ‘Wrong’ Way?” 🙂

          • KeeperOfTheBooks

            We are freaking lucky with our insurance. I describe it as pretty much the Lamborghini of insurance plans. (Of course, between us and DH’s work’s contribution, we’re also paying $1200/month for it, so…yeah.)
            Heh. I like it! My guess is that All The Cool Babies (TM) want to stand out from the crowd, not get into one of those same-old, same-old head-down/easy-(well, relatively) out positions. Mine managed to get herself squirrelled around in there with one foot under her and leaning somewhat backwards, rather like a Russian folk dancer. The ultrasound tech found it hilarious, as did I. Those late 3D ultrasound photos of it were cute, but one foot and butt coming first with the torso and other leg angled out and away from the pelvis isn’t exactly an ideal presentation for vaginal delivery, speaking as the person whose vagina it would be…

        • Elizabeth A

          Our insurance was similar – I paid one single-visit co-pay for each pregnancy. Even when I wound up at the ER at a different hospital, even when the CNMs transferred me up the chain right out of their hospital. Everything. From the first prenatal to the NICU stay, ambulance rides included. One copay.

          Compare to cancer, which included a white-knuckle conversation with the hospital’s patient finance department about how we were going to pay for this.

          I want it to be like my OB care for everyone, for everything.

      • nomofear

        Cha-ching! I leaned woo when pregnant with my first, and, since insurance covered an OOH birth center, I ran with it. Horrible idea, but luckily, we came out alive and well. I realize now that was luck. And, after our insurance reviewed them after we mentioned some things, they dropped them from coverage. So hey, at least there’s that!

    • yugaya

      Insurance fraud means close inspection and more automated process of charging them than the medical board reviews and complaints. Their maneuvering space to practice illegally like that has been significantly reduced by this legislation.

    • Medwife

      Oh, they will absolutely commit more of that type of fraud. Bet on it. But anytime someone transfers, including for things like pain relief, there will be an opportunity for their charting to be audited and for discrepancies to have real consequences. Much better quality control.

  • Amazed

    That’s a great news! A true start, thanks to the efforts of everyone conducting well-designed studies, everyone willing to show them over and over again until those in power listened, everyone who went against the wind publishing articles that exposed CPMs for what they are. And of course, Dr Amy, those people who were determined to not let their own suffering be buried silently and waved away but instead used to highlight the problems in the homebirth system. And all those who put work and efforts int achieving this result, many of whom are regulars here.

  • theadequatemother

    I want to congratulate and thank all of those, many of whom are regular readers here, for their hard work and persistence in getting the truth out there. You guys are angels.

    • Mer

      of which you are one of, your posts on epidurals are always helpful!

  • attitude devant

    The amazing thing about the Oregon effort was that it was truly a coalition of mothers, nurses, CNMS, doctors, and public health officials who made it happen. But I think they would have not gotten nearly as far without the bravery of people like Kristine Andrews and Margarita Sheikh, who never stopped reminding people of the harm done to their sons.

    • Karen in SC

      I was thinking of Abel when I read this. Did the Bend Bulletin connect the dots with their article?

    • Sue

      Congrats and kudos to all those who contributed. It;s times like these when you know that activism is worthwhile.

      • attitude devant

        If anyone wants to know what it took it was this: over five years of networking, speaking out, lobbying, coalition-building, hammering at the status quo from every angle: laws, insurance, midwifery boards.

  • hmmm

    If crunchy Oregon won’t pay, sounds like more of this will happen in the future. Gonna be some mad quack midwives in the world. Maybe we should just call them CNMs and quack midwives.

    • yugaya

      If Oregon Medicaid won’t pay, I doubt private insurers along with other states will ignore this clear and absolute minimum risking out criteria.

      This is huge.

    • Mer

      maybe midquacks? Or quackwives?

    • Who?

      Birth hobbyist?

    • Bombshellrisa

      I thought we agreed “woo witch” for the fake midwives

      • Sue

        Or Midwitches

        • Daleth

          Nope. See Blue’s comment above.

      • Blue Chocobo

        I don’t like “witch”, I’ve known too many very nice, reasonable, non-baby threatening pagans who seriously use it as a religious description.

        • Daleth

          Thanks, Blue. I agree.

      • Amazed

        *I* haven’t! Sounds too much like the wood witch from A Song of Ice and Fire.

  • manabanana

    The midwifery bridge certificate is a JOKE. A flaming, stinking, ridiculous JOKE. It’s a bandaid on a hemorrhage. Look deeper.

    “50 accredited approved continuing education contact hours (CEUs/CMEs/CNEs) within the five-year period prior to application. ”

    Let’s not be complacent and imply that NARM is actually requiring anything… 10 CEUs per year for the 5 years leading up to the bridge requirement. This will probably double count for CPM recertification. AND accredited through whom? MEAC? HAHAHAHAHAHAHAHAHAHA! They accredit midwifery CEUs on making placenta smoothies and full-moon drumming for goddess worshiping midwives.

    AND – please note – the bridge certificate is as stop-gap for the least trained CPMs (the apprentice trained, PEP ones). And will ONLY be required in the states requiring this IN THE FUTURE. Which has not yet happened.

    50 CEUs in whatever is NOT enough. NOT. Not even close!

    It’s all a ruse. A ruse.

    • manabanana
      • moto_librarian

        Why can’t the ACNM start lobbying against this bullshit? I would think that the majority of CNMs would be tired of the antics of these midwives, or is the leadership of ACNM too deep in the woo to do anything about it? I feel really disappointed that the ACNM essentially condones these other credential. We don’t need “sisterhood” – we need professionally educated and trained CNMs.

        • yugaya

          ACNM refused to acknowledge (like ACOG did this year) that CPM credential is substandard and that all women in USA deserve at least an ICM standard of care educated birth attendant: http://www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Endorses-the-International-Confederation-of-Midwives-Standards-for-Midwifery-Education

          ACNM is infested with the diseased cult of natural birth supremacy and influenced on the whole by ‘midwife is a goddess’ ego stroking of MANA. Hopefully that will change soon too, but not before the entire upper echelon of ACNM is sacked. They are all too deeply involved in being fake midwife apologists.

        • Sue

          EXACTLY.

          Lay MWs are an insult to trained, professional MWs. If I was a CNM, I would be fuming that LMs and CPMs could be paid to be doing something that I had invested time and energy in training for. Doctors and other nurses would not accept working alongside hobby-ists – it’s illegal.

          • The Bofa on the Sofa

            Lay MWs are an insult to trained, professional MWs. If I was a CNM, I would be fuming that LMs and CPMs could be paid to be doing something that I had invested time and energy in training for.

            You would think…

        • manabanana

          Why can’t the ACNM start lobbying against this bullshit?

          The ACNM is lobbying FOR it as one of the members of MERA.

          http://www.usmera.org/

          Why is the ACNM, the ACMB and ACME promoting any standard for midwifery education or practice that does not meet their own standards?

          Beats. Me.

          Maybe they believe that this kind of shenanigan promotes diversity and inclusiveness or something.

          I would prefer that the ACNM unapologetically promote excellence and competence in midwifery. Hanging with NARM, MANA and the crew is not doing that. At all.

  • Roadstergal

    Restricted HB in Oregon and elimination of the Personal Belief Exemption in California? Really, two developments I did not see coming – but particularly not in these states. It gives me some hope.

    • AirPlant

      My Theory? In places like Michigan the crunchy:standard ratio is small enough that the catastrophies are relatively rare. Oregon and California have crunchy coming out of their pores and emergencies will correspondingly be more common and a bigger problem for the state to absorb. It makes sense that they would have to crack down. They are the ones experiencing a problem

      • Roadstergal

        That’s a good point. After all, it was CA who had the measles outbreak that made the news (and a rather good Jon Stewart rant).

        • The Bofa on the Sofa

          And it is consistent with my regular contention that “the problem with drunk driving is not the risk, but the prevalence. If drunk driving were as common as homebirth, no one would care”

          That means the converse is also true: if homebirth were as common as drunk driving, it would a national disaster. Places of high prevalence are most likely to notice the problem.

  • Ash

    The document says “approved”…is this document in effect right now?

  • CrownedMedwife

    THIS is phenomenal. Finally.

  • Are you nuts

    I’m curious how many births a CNM would participate in as part of their clinical training? What about an obstetrician?

    • PrimaryCareDoc

      OBs are required to have at least 200 spontaneous vaginal deliveries. Most have much more.

      https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/220_Ob_Gyn%20Minimum_Numbers_Announcment.pdf

      • Blue Chocobo

        You mean there’s no medical school requirement that all births attended have all possible interventions to ensure that OBs have never seen a “normal” birth? Could’ve fooled anyone who believes a CPM…

        • Megan

          Oh, yes. Whenever mom was progressing nicely, we’d say, “Let’s give her some pit, just to see if we can get some decels; then we can section her and be done with it!” Or whenever things were going “too well” during pushing we’d always say, “Hey, pull out the forceps. This is boring!” We certainly didn’t just stand there with a smile on our faces and say, “I’m so glad this is going smoothly.”
          /sarcasm

        • Roadstergal

          I can just imagine CPMs bleating that the spontaneous vaginal delivery minimum for OBs doesn’t specify the absence of pain medication, so they’re not ‘real’ spontaneous vaginal deliveries.

        • yugaya

          I was just reading this stinkin’ pile of bs ( starts on page 89 with fake midwives’ testimonies) and one of them said with a straight face that CNMs are not trained to take care of newborns as well as the CPM/DEM/LM clowns are

          “we actually have more training and caring for midwives than those CNM’s do” (page 109)
          “Because nurse midwives in a hospital do not care for newborns at all, that never includes newborn education.” (page 99)
          ” So, this is not something that would have been caught in the hospital” (page 102)

          http://www.doh.wa.gov/portals/1/documents/pubs/631045.pdf

          • CharlotteB

            I don’t remember who did the newborn exam (I had a CNM-attended hospital birth)–but midwife means “with women” not “with baby” so I wouldn’t expect that a midwife (or OB, really) would be trained in newborn care other than the initial exams, emergency treatment, and warning signs, so they can get the appropriate specialist.

            Obviously, I’m sure that CNM are better trained than CPMs when it comes to newborn care, but that’s not their primary role.

            I know when I had my son, I was told that there would be an L&D nurse and the midwife during labor (through 3rd stage), and (I think?) an additional nurse for the baby when he showed up. I honestly don’t remember if anybody came in the room, but it makes sense to me that even an excellent, well-qualified CNM wouldn’t need extensive, specialized training in newborn care since they can call for backup.

            Plus for all their supposed education, CPMs don’t have a great track record when it comes to appropriate newborn care…

          • yugaya

            Compulsory clinical training in newborn care including high risk newborns is part of CNM education.

          • CharlotteB

            Oh, I’m sure it is and that they’re vastly more qualified to care for babies than any CPM. My point is more that it’s especially stupid for CPMs to act like they’re any better at newborn care since 1. They obviously aren’t and 2. most of the time, they seem to give little thought to the baby’s health anyway. Neither one is a neonatologist, for example, but I’m going to bet that the CNM would be much more able to collaborate with a neonatologist and help the parents understand the situation as compared to the CPM who’d probably just tell you to breastfeed more.

          • Dr Kitty

            In fact looking at the list of conditions apparently picked up by CPMs, I’m going to put money on ALL of them presenting as feeding problems, not that they were picked up during a thorough newborn exam.

            Prader-Willi and Downs can cause a weak suck.

            Failure To Thrive is a diagnosis meaning “the baby isn’t growing”, which probably, in this scenario, is IGT and insufficient milk. Wonder how many centile lines the baby crossed before the CPM was willing to admit the solution wasn’t just “offer the breast more”?

            Pyloric Stenosis usually presents at two to six weeks with projectile vomiting which progresses over 24-48 hrs to an angry, hungry, very unwell baby with metabolic alkalosis, hypokalaemia and severe dehydration. A baby who should have gone straight to the ER after those symptoms were described on the phone, and shouldn’t even have made it as far as a CPM’s office. Saw some of these babies when I worked in a press ER… Any lay person knows they’re really unwell.

            Congenital heart disease often presents as babies who are exhausted by the physical effort of feeding, so they are sleepy and won’t feed for long, or they turn blue when feeding.

            So…
            My guess is that every single problem was picked up when there were issues with feeding. NOT reassuring.

          • Bombshellrisa

            You are right, especially in light of the fact that one of the CPMs that was part of that discussion is Elias Kass, who specializes in frenectomy.

          • Dr Kitty

            Also, do you remember NGM didn’t know why checking red reflex was important?

            Both my kiddos had their newborn top to toe assessments done by UK midwives before we left hospital. #1 got a paeds assessment when the MW thought there was a sacral dimple, a physio assessment for positional talipes and a hip ultrasound arranged, because of uneven skin creases. #1 has a perfect spine and hips and her foot self corrected before she was six months. With my history no-one was taking chances with her.

            #2 failed his day 1 newborn hearing screen the first time, and even though I wasn’t particularly worried, the technicians took time to reassure me and the repeat was fine. When the MW was doing #2’s check she even asked me if I wanted her to repeat anything, or do anything for my self, or if I was happy to take her word for it that everything was OK.

            Thorough newborn checks by properly trained professionals are invaluable. Counting fingers and toes and noting that the baby is pink and feeding like a champ Is less helpful.

          • Bombshellrisa

            Also part of nursing school, so it’s not like a CNM would be going into clinical practice or even CNM school without some background in it.

          • Bombshellrisa

            The Washington midwifery association president Val Sasson is the midwife who let my friend push for six hours before transferring her to the hospital. Hey, if she can’t transfer a woman at 41w6d who has been laboring for a few days in a timely fashion, what makes anyone believe she knows how to do proper newborn care

          • yugaya

            Valerie Sasson is a complete idiot. An individual who is incapable of using formal, professional register while speaking as a president of midvwifery association during a public hearing is probably not qualified to deliver medical care to anyone in any capacity. Makes it perfectly clear how stupid and unprofessional the lot of them are when their president stands up at a DOH hearing and says this:

            “Those of you who have been with brand new parents know that as soon as you have a brand new family in a home with a new baby, the shit hits the fan. They really have, you know, it is a very disorienting time of life. And so, there’s really no other way to say it.” ( page 90)

            There are plenty of ways to say it using formal register that is the only appropriate one to use in that situation. For the life of me I don’t understand why whoever was presiding over that hearing didn’t just throw her sorry ass out immediately.

            I’m not surprised to hear that she provided such substandard and dangerous care to your friend.

          • Bombshellrisa

            She teaches part of the midwifery program at Bastyr.
            http://makinganddoing.blogspot.com/2011/08/elliotts-birth-story.html
            If you scroll down, there are pics of student Sarah (whom attended my friend’s birth) and Val, who is “watching” the laboring mother.

          • yugaya

            “Val, who is “watching” the laboring mother.”
            …by sleeping on the couch.

            If I hadn’t read enough quack midwifery papers that go to great lengths to claim how a midwife knitting in the other room or doing just nothing is supposedly using her *special* powers of monitoring, I would have been surprised by such advanced technique of ” watching the labouring mother”.

          • mythsayer

            The baby came out blue! BLUE! And after he “pinked up” his hands were still blue! I’d have been freaking out!

          • Montserrat Blanco

            She has no idea what being a new parent is. Nothing hit anything in our case. And we had a preemie. When he arrived home we did not sleep for a few days, but nothing else.

          • Bombshellrisa

            I never felt like anything was hitting anything else. It was a different schedule when my son was born, because I had to pump but it felt pretty calm here. Aside from the not sleeping part.

          • CharlotteB

            Wow, I’m skimming over that and so much of it is basically about breastfeeding–not so much baby’s health, but breastfeeding. Not baby’s health or weight gain (nowhere do I see “recommendations about supplementing”) but just breastfeeding.

          • yugaya

            And bonding. They are qualified to assess breastfeeding and bonding. Their knowledge is so superior that they have to translate for us unenlightened what they do. :

            ” You’ll forgive my midwifery speak. We catch babies, we tend clients,you know so if you need me to translate that, please let me know. But, hopefully, you catch my drift.”

          • CharlotteB

            Right. Because bonding is very clear-cut and quantifiable in a 3-day old newborn.

          • Sarah

            Although unfortunately that behaviour isn’t limited to midwives.

          • CharlotteB

            I’m pretty sure we live in the same general area, assuming your friend also lives here.

            The person who taught my birth class makes an appearance in that transcript…

          • Megan

            Wait, wait, wait, these CPM’s are trying to EXPAND their scope of practice to include newborn care?? Are you kidding?? I would never trust my baby to one of them. It’s not enough to be lay midwives? Now they want to be lay pediatricians? Christ on a bike…

          • Bombshellrisa

            It’s about reimbursement by insurance, it always comes down to money with a CPM.

          • yugaya

            This Oregon regulation is hitting them exactly where it will hurt the most. I can’t recall the last time I saw such a staunch no to fake midwives change in regulation in recent years.Now it will be easier to push similar risking out regulation in other states.

          • Bombshellrisa

            What I am hoping is that it doesn’t make women who have known risk factors use midwives for prenatal care, have the midwives there unofficially at the birth but declare they are doing a UC and then if everything is ok have them still get paid. There are midwives who give “unassisted birth classes” and still get women to hire them as doulas.

          • Who?

            You can’t fight stupid, more’s the pity.

          • Roadstergal

            They can still bilk individual women out of money, but at least now they can’t bilk all of us at once.

          • yugaya

            They will be easier to catch and ban. I know that this is an ugly truth to state, but being investigated and found guilty of insurance fraud is more likely to stop them from delivering babies than complaints for killing and injuring babies to medical boards and current laws are.

          • An Actual Attorney

            Medicaid fraud is a federal crime. Federal prison is not a knitting circle.

          • Who?

            We may be about to find out exactly how far the hubris and stupidity of these people extends.

          • demodocus

            A CNM has baby sat my kiddo, but the closest to newborn care she’s done was “ooh! Can I hold him while you get your music folder out?”

          • Bombshellrisa

            From one of the testimonials written by a WA CPM “Over the course of my career, I have identified critical health issues in newborns prior to an appointment with their chosen pediatric doctor. Because of our early and meticulous follow-up after birth, we are able to identify early feeding issues/problems and prevent serious weight loss. Some of the more serious issues identified have led to the following diagnoses: Down Syndrome, Prader Willi syndrome, congenital heart defects, jaundice, failure to thrive, pyloric stenosis, prolonged Q-T syndrome (heart abnormality). In some cases the families we serve are disinclined (against our advice) to take their newborn to any other provider in the early weeks of life. The trust they have in us and our skilled care ensures that their newborns are followed closely in the early days and weeks and any abnormality is identified early and appropriate care is arranged. ” Nearly anything that this CPM noticed AFTER birth would have spotted before birth if the mother had proper prenatal care.

          • yugaya

            This lot is supposedly capable of all that?

            “MEGHAN PORTER:Yes, but, you’re saying, you know, you want to have the standards on your website that are going to change based on what’s going on. Well, what if somebody got their license 20years ago? they’re not a member of the association,and this guidance is changing constantly. How do they know what the change is and if it’s not defined in scope, what if you reach beyond the scope? If you reach beyond the scope of what your scope is,because of the guidance on your website, how do youknow when to stop? Where is that grey, where is that area where you say, ok this is going to be a scope of practice change?

            VALERIE SASSON: Now, I can understand, I hear your concern. It would be great if we could have 100% compliance. I’m pretty sure that our compliance is better than ACOG honestly in terms ofmembership. But what we…

            MEGHAN PORTER: I don’t know what ACOG is.”

            She don’t know nothing, not even what ACOG is or what continued professional education entails. And yet we are supposed to believe that she is qualified to safely deliver human babies and identify what is normal and what is a life-threatening complications in newborns.

            Give me a fucking break, thank you Oregon legislators, and we need more of the same as soon as possible so that caricatures like Meghan Porter are never licensed and allowed to attend births anywhere.

          • CharlotteB

            I could be wrong, but I think Meghan is with the department of health. She might not have all the abbreviations at her fingertips. Edited to clarify: I don’t think she’s a midwife.

          • yugaya

            Lol you are correct.

            *crosses fingers in vein hope that Meghan did not have any voting rights over midwifery bills*

          • Dr Kitty

            Notice the way that is oh, so carefully phrased.
            The CPMs identify issues which led to diagnoses.

            Because if they were diagnosing these conditions themselves they would be arguably practising medicine without a licence.

            They are also careful to call themselves providers who identify abnormalities so that appropriate care can be provided.

            The baby still has to be taken to a Dr if the CPM thinks there is a problem.

            So, what we’re saying is that CPMs are totally confident that they will NEVER miss an abnormality, and that if they say everything is OK with the baby, their clients don’t need to see a Dr.

            In fact, what they’re saying is that they are experts in normal babies…

          • Sue

            Also, “The trust they have in us and our skilled care” means that they wait for the CPM to dientify a problem, as opposed to going straight to a real health care professional, in the absence of the CPM.

          • Azuran

            wow, she was able to identify a baby with down syndrome. I’m impressed.

          • Sue

            “Because of our early and meticulous follow-up after birth, we are able to identify early feeding issues/problems”

            We have hospitals, general practitioners, pediatricians and early childhood nurses for all that – trained professionals, all of them.

          • Blue Chocobo

            If my newborn needs care, I want a neonatologist, NICU nurse, pediatrian, or peds specialist nurse. Not someone who specializes in treating birth like a really spiritual game of catch.

            CNMs (generally) will call a newborn specialist if one is even possibly required. CPMs “specialize” in making everything a variation of the “normal” they’ve declared themselves experts in.

    • manabanana

      Unfortunately – for people who enter nurse-midwifery without working as a nurse – they would have participated in very few births. 20 births as primary for CNMs is the minimal requirement set forth by the ACME – though individual graduate programs set their own minimal number of births from 20 – 60 labor and delivery managements. (There are additional clinical requirements – but the minimum number of labor and birth managements is 20).

      For midwives who enter midwifery after a career in nursing (specifically labor and delivery), these individuals will have attended hundreds of labors and births. The clinical requirement trains these nurses to enter the advanced practice role as the CNM. They will enter the profession with a lot of labor and delivery experience.

      I don’t think the minimal requirements are sufficient for midwifery students who do not have significant L&D experience prior to entering nurse-midwifery school.

      I would love to see a study in the US similar to the study done in NZ comparing first-year CNMs – those with previous L&D experience, and those with none.

      • Are you nuts

        Wow! That’s a really low number!

      • CharlotteB

        How often does that happen though? It seems like you’d have a hard time getting accepted to a grad program if you’re competing with people who have L&D experience.

        • manabanana

          It’s not as hard as you think. I have no idea how many student nurse-midwives do not have L&D experience, but it’s not an insignificant number.

          Think about it, though. If you’re an RN and you want to work in L&D, you need experience – it’s very hard to get an L&D job without experience. The employer doesn’t want to take a risk hiring an inexperienced new nurse. If you want to go to graduate school, you just need to pay tuition. Grad schools like tuition. Tuition is money, and what’s the risk to that?

          I’m currently an SNM, and in one of my midwifery courses, 1/3 of the class had NO L&D experience. Nada. Zilch. Nary seen a babe nor placenta born.

          That’s just a convenience sample for you – and it tells me that it’s NOT HARD to get into a midwifery program with little to no experience. (Ummmm, which is SHOCKING).

          Back to the orignal question – how many births are required for CNMs in training? 20.

          That’s not enough for nurse-midwives who enter the profession without prior experience. Not even close.

          • CharlotteB

            WOW. I’m really surprised by that. I do understand the experience issue (which affects lots of professions) but how would you even know you wanted to be a midwife if you’d never seen a birth?

          • manabanana

            Great Question!

          • Squillo

            I’ve heard mixed things about bachelor’s-to-master’s programs for advanced practice nurses in general. There is definitely concern out there that they may not be adequately trained to really practice to their full scope. It’s my understanding that this is the model many European (and some African) midwifery programs follow, while there’s been a push to get APRNs and midwives in the U.S. transitioned to DNP-level preparation.

          • Ash

            I’ve heard that the MSN and DNP programs don’t vary that much in terms of clinical experience, although the original intention of creating the DNP program was to be more clinically oriented than a PhD in nursing.

      • Sue

        Call me old-fashioned, but I’m yet to be convinced that direct-entry CNM training can deliver as much clinical input as general nursing training with later MW specialisation.

        Most mothers are healthy young women, so the catastrophic deterioration – thankfully – is less common than in other areas. It’s hard to imagine that you don’t learn more about shock and sepsis better in the ED and the surgical wards than in L&D.

        What do the CNMs here think?

        • KarenJJ

          For many of us “healthy” young women pregnancy is the first time any of us have ongoing regular contact with a health professional. A few people I know (including myself) have come to find very odd and strange issues that were lurking while we were pregnant. Plus some people that have other underlying issues – mental health, recurrent UTIs etc can also be referred on better than someone that has only done midwifery training.

    • Gene

      I can tell you that I was required to deliver 10 babies during my Peds ED fellowship. Considering that I’ve delivered almost that many as an attending at my current hospital in the past 3 years… Most of my Peds ED colleagues rarely deliver babies in the ED. My hospital seems to specialize in the “screech into the ED parking lot” precipitous labors. I can’t remember how many births I was required to attend as a resident (not delivering, but running the newborn assessment and resus if needed). But I stopped logging them after 150 in the first three months of internship. And we were only required to attend a birth that has issues (meconium, decels, distress, etc etc). I joke that if a woman arrives in labor, you want me on the baby end, not the mom end.

      Even with ALL this experience, I still am vastly unqualified to deliver babies except in emergency situations. Even then, I’m hoping that OB shows up before I have to catch.

    • Megan

      I am a family doc and as a FP intern I did over 100 deliveries that year alone. (Granted, I interned in an unopposed residency program so I got more OB experience than most FP interns.) My experience pales in comparison to that of a OB resident who likely would do even more.

      • theadequatemother

        I delivered 30 during my OB rotation as a medical student and another 60 during my general rotation year as a first year anesthesiologist resident. And then one during an epidural call. Many prenatal and postnatal visits too. I had to be able to interpret CFM for my anesthesia exam and be certified in NRP (which is a joke compared to taking a neonate to the OR for removal of dead gut from NEC). I still don’t think I could manage the decision making required to properly bring the mother-baby dyad through labours. Nope. Calling a professional. Because I’m about as good at catching as a taxi driver and I wouldnt trust myself to properly repair a perineal tear.

        • Mer

          So you got called in for an epidural and ended up catching the baby? That’s kinda cool, as long as it was one of those everything went well births.

    • attitude devant

      I delivered about 2000 in training. (OB)

      • Amazed

        That’s a lie! I know you only caught 75 natcherel baybeees in your training! Abby R. said so!

        • Happy Sheep

          Best part is, it’s ONLY 75 natural because she’s an OB. If she was a CPM it would be “She’s sooooooo experienced, she caught 75 babies in training!!1!

    • manabanana
  • RMY

    That’s great. It’s nice to hear good news these days.

  • Megan

    Fantastic!

  • moto_librarian

    It will be a happy day indeed when the CNM is the only credential for midwifery in the United States.

  • Daleth

    This is just wonderful news.