The challenge of the cultural divide continues to be an obstacle to resolution, with both “sides” feeling conflicted. While there are distinct moments of mutual agreement about issues and concerns that come at each meeting, this feeling of movement is tempered by the untenable areas related to patient autonomy and physician supervision. Following the meeting, for which minutes are not yet available, Deren and I sent the following letter to Board of Medicine Executive Director, Dr. William Harp:

Dr. William Harp
Executive Director
Virginia Board of Medicine
Perimeter Center 9960
Mayland Drive, Suite 300.
Henrico Virginia 23233-1463

Date 5/8/11

Dear Dr. Harp,
After our fourth meeting last week it is clear to us, as representatives of the midwifery and home birth community for the Workgroup that an impasse has been reached between medicine and midwifery. There is an obvious and immoveable sentiment among members of the Workgroup who represent the full Board that there will be no endorsement of a plan to allow access to medications for midwifery clients without agreement to restrict access to home birth. Additionally, there is resolute resistance to the concept of drafting model language that would allow the use of medications by any providers who are not supervised by physicians.

Though there was some tentative discussion at the last meeting of issues directly related to access to medications such as protocols and training, the vast majority of our time was spent revisiting the conflicts over standard of care and physician/midwife relationships. Persisting in this dialogue is not productive toward the goal of the Workgroup. As the representatives of Virginia midwives on the workgroup we do not have the blessing or the authority to negotiate issues of midwife autonomy and risk screening. The suggestion by Workgroup members that midwives give up the right to care for women with potential risk factors would likely lead to an increase in unlicensed midwifery practice or unassisted birth. To close one gap in care by opening another one would simply compromise safety in a different way. We cannot see the point in continuing to respond to requests for research. There is no amount of data available that can justify the continued lack of access to basic medications for clients in midwifery care. Neither can we agree that restricting risk factors for home birth will impact the suitability for the use of these medications by well-trained midwives attending births outside the hospital environment.

In order to move forward in a way that justifies the public cost and respects the time and energy of the Workgroup members, we feel that the staff at the Board of Medicine should be directed to draft model statutory language which would outline a mechanism for obtaining, carrying, and administering medications by Licensed Midwives that does not include physician supervision. All of the members of the Workgroup have agreed that supervision is not tenable at this time. Physicians are unwilling to assume liability for the actions of midwives, and therefore midwives are unable to find physicians to supervise them. An autonomous mechanism seems to be the only remaining solution.

As Brynne stated during our last meeting, the midwifery community accepted licensure without access to medications because we knew that practicing with a legal status would increase the safety of home birth and the accountability of the midwife providers in the Commonwealth.

We continue to believe that access to basic emergency and newborn medications would make home birth safer for mothers and babies, but we cannot continue our participation in the workgroup without action and input from staff expertise at the Board of Medicine and an indication that our fellow Workgroup members are committed to helping us solve this problem.

We respect the effort and intention put forth by the Board of Medicine in the creation of this Workgroup. But until a will exists among members of the group and of the full Board to acknowledge the need to move forward with a mechanism for medications without an agreement for practice restriction, we do not believe our efforts are serving the public and we respectfully request that the effort be tabled.

Sincerely yours,

Brynne Potter, CPM and Deren Bader, CPM, DrPH

At this time, we have had no response and a next meeting has not been scheduled.  What are your thoughts on next steps for Virginia midwifery?

Suzie contemplating her potential…

When President Obama signed part two of the Health Care Reform Legislation [The Health Care and Education Reconciliation Act of 2010 ("Reconciliation Bill")] on March 30th, a provision of the FSLA (Fair Labor Standards Act) was amended to require employers to provide space for working moms who need to express breast milk.

A new paragraph (r) is added to Section 7 of the FLSA that requires employers to provide unpaid, reasonable break time for nursing mothers to express breast milk, as such employee has need to express the milk, for one year after the child’s birth and a place to express the milk “other than a bathroom, that is shielded from view and free from intrusion.” An employer with less than 50 employees will not be required to implement this provision if doing so would cause the employer an “undue hardship.”

This provision is effective immediately.

A great step for healthy babies.

How many of you have pumped milk or nursed your baby in a bathroom?

Not in the opinion of the Commonwealth of Virginia.
As a follow up to last year’s passage of legislation that would require evidence-based informed consent for all women seeking home birth Evidence Based-It’s Now the Law, the Virginia Regulatory Townhall posted the first of two public comment opportunities.
Please read the following open letter to Midwifery Advocates and take a moment to post a comment to the Commonwealth of Virginia regarding your thoughts on informed choice in maternity care.

Dear Midwifery Advocates, Researchers, and Educators -

I am writing on behalf of the Certified Professional Midwives licensed in Virginia to ask for your support involving establishment of regulatory precedent for evidenced-based informed consent for women seeking maternity care.  As some of you may already know, last year the VA General Assembly passed a bill that required CPMs to provided evidenced-based informed disclosure to all women seeking home birth. You can read the history of how this happened here:  http://midwifemonologues.com/making-lemonade-a-recipe-to-support-hb-2163/

Risk factors that were listed in the law included vbac, twins, and breech presentation but also allowed for “other high risk pregnancies”.  The law does not state that these conditions would prohibit CPMs from attending a woman at home, just that the CPM will be required to provide clear, evidence-based informed consent before doing so.

The process that follows a statutory mandate for regulatory change in Virginia is open to the public and participation is simple.  The notice of intended regulatory action (NOIRA) has recently been posted to the Virginia Townhall Website.  The summary and details of the guidelines for this regulatory change are listed in a pdf (here) and there is now a 30 day public comment period.  Comments can be submitted by any member of the public, both in Virginia and outside of the state.

After the comment period ends (11/25/09), a Work Group consisting of members of the Board of Medicine and the midwifery community will convene to come up with a list of conditions that require additional informed choice, and draft specific informed choice documents that will be included in the regulations for CPMs.  These documents will then be presented to the Advisory Board on Midwifery and the full Board of Medicine for review.  There will be a public hearing and then another 30 day public comment period before final approval.

The midwifery community in Virginia believes that even though this requirement is redundant to our existing statutory requirement to practice the Midwives Model of Care, which is based on informed choice, the opportunity to establish once and for all that women are choosing midwifery care and home birth of their own free and informed will, is worthy of our close attention and support.  We believe that if we can engage the Board of Medicine in an unprecedented process of looking at evidence-based criteria for competent practice, we will widen the narrow band of understanding that is forming between medical and midwifery based maternity providers.  In addition, we need to be vigilant during the process to make sure that any guidelines or rules established do not create unforeseen obstacles to care for women who may fall into gray areas regarding relative risk of home or hospital birth based on current standard of practice in many hospital settings.  Mandated c-sections for VBAC, twins, and breech are good examples of the conundrum many midwives and their clients face when providing and making informed decisions for care.

We ask that you review and consider this outlined process and then post a comment to the Townhall Web site.

For those of you with a background or expertise in evidenced-based maternity care, please include your credentials and give citations to your work or other relevant resources that you can provide to the Work Group.  The NOIRA specifically states that the department plans to look to other states with various models of reviewing and determining risk. Item number 3 under “Substance” is especially interesting and invites response:

“If the factors or criteria have been identified that may indicate health risks associated with birth of a child outside a hospital, a requirement for the midwife to provide evidence based information on such risks. Such information would be specified by the Board for certain conditions and would include statements and evidence from both the medical and midwifery models of care.”

It appears that the agency believes that “evidence” is a subjective term and that is why we need evidence from both sides.  While I commend the Agency in its efforts to be fair and balanced, I believe this statement shows how imperative it is that we provide them with clear and objective evidence (research) from which to draft their documents.

For those of you who have used, are utilizing, or intend to use maternity services in Virginia, please tell the Agency what you would like the documents to include.  It is up to you to remind them that you want your informed choice to include the risks and benefits of home birth and that you want your “evidence” to be based on research, not opinion.  It is up to you to ask for information on the risks of hospital or caesarean delivery in certain situations as part of complete informed decision making. It is also up to you to review the current midwifery regulations and comment on any other aspect or restriction involving access to care that you believe should or could be improved.  They are asking for your opinions and this is a great opportunity to give them.

By providing  your comments, you support and engage the process.  You also remind everyone involved that the process is being carefully watched.  Most importantly, your comments may have a ripple effect in creating a future where ALL maternity providers are required to give evidenced-based informed choice to their clients.

Thank you for your time and attention. Please forward this request to anyone in your contact list that you believe would want to have this opportunity to participate in this process. Feel free to contact me with any questions or concerns.

Brynne Potter, CPM

Legislative Policy Coordinator, Commonwealth Midwives Alliance

brynne@mountainviewmidwives.com

www.mountainviewmidwives.com

o: 434-962-0148

m:434-962-5453

The monthly Birth Circle meetings sponsored by Birth Matters Charlottesville have become incredibly popular in the midwifery community.  These informal gatherings generally involve birth stories, resources sharing, and building connections among expecting and new moms in the Charlottesville area.  The group is not midwife or home birth exclusive. In fact, the compelling nature of the group comes from the respect of all perspectives on birth choices and options.

The gathering is girl heavy.  And at the request of a few regulars who want to bring their guys for a fun night out, Birth Matters is sponsoring a Couples Birth Circle on January 23 at 7pm at the Body Mind Spirit yoga studio at 923 Preston Ave in the Preston Plaza (next door to Integral Yoga Natural Foods). 

Can’t wait to hear how it goes!