Utah Medical Association is trying to eliminate home birth again.

The witch hunt continues. Really, this is nothing new, but it is always frustrating. Marsden Wagner, world-renowned perinatologist (ie. “high risk” pregnancy doctor), is a vocal supporter of home birth as a safe option for most women. He’s also well aware of what he calls the global witch hunt against midwives. Obstetricians and other hospital care providers (such as certified nurse-midwives , nurses, and family practice doctors) have long waged a war against out-of-hospital midwives. Their battle cry is “Safety! We must protect women and babies from dangerous, unskilled midwives!” Their motive, however, is actually a combination of money and power. From Marsden Wagner’s “The Global Witch Hunt“:

“The witch-hunt is part of a global struggle for control of maternity systems and there are several key issues, one of which is economic. An obstetrician in private practise in Des Moines, USA, told me that he and the other obstetricians in that city were determined to close down the only alternative birth centre, staffed by midwives, because “it is stealing our patients” (Shortly after this remark, the only doctor in the city willing to back up the alternative birth centre retired and, since no other doctor would provide such support, the centre had to close.)… However, in the face of increasingly limited economic resources, governments and insurance companies are becoming more and more concerned with the waste associated with high-technology, high-intervention obstetrics. It is much more difficult for obstetricians to defend this expensive type of practice when midwives and a few doctors are meanwhile showing that a much less expensive type of maternity care is equally safe. The witch-hunt is an attempt to display lack of safety among the competitors.”

And:

“A second issue is the control of maternity services. Until recently, government regulations in most countries have given medical doctors a monopoly in providing health services.”

You see, if these self-proclaimed logical scientists actually looked at the data on planned, midwife-attended home birth they’d realize that they have absolutely no grounds to charge midwives as being unsafe care providers.

Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”Johnson, K. and Betty0Anne Daviss, “Outcomes of planned home births with certified professional midwives: large prospective study in North America“, British Medical Journal

In his article, “Fish Can’t See Water”, Marsden Wagner says:

“Showing women—half of all people—that they are inferior and inadequate by taking away their power to give birth is a tragedy for all society. On the other hand, respecting the woman as an important and valuable human being and making certain that the woman’s experience while giving birth is fulfilling and empowering is not just a nice extra, it is absolutely essential as it makes the woman strong and therefore makes society strong” (“Fish Can’t See Water“).

So what’s happening in Utah? Well, in 2005 the Utah State Legislature passed the Direct-Entry Midwife Act. This law expressly legalized non-nurse midwifery as a distinct profession with its own unique rules of practice. Prior to the passage of the law, the Utah Medical Association (UMA) formally dropped their opposition after some compromises were made to the bill as did the state’s Certified Nurse-Midwife organization. Utah’s Direct-Entry Midwife law is a wonderful piece of legislation that strikes the delicate balance between Licensure is voluntary. Those midwives who wish to carry certain emergency medications must license in order to do so. As is standard procedure, there was a rules hearing process during which the Licensed Direct-Entry Midwife board defined a Utah LDEM’s scope of practice.

Three direct-entry midwives, one certified nurse-midwife (CNM), one member of the public, one naturopathic doctor, and one obstetrician were appointed to this board. Throughout the rules process there were rules hearings (during which the UMA voiced objections) and there were working meetings (during which public input was considered). The Utah Medical Association (UMA) did not choose to attend any of the work meetings and the obstetrician never came to any of the meetings, either. Now the UMA has brought foth its second legislative attempt to re-write the circumstances under which a direct-entry midwife (licensed or not) can practice. They introduced a bill last year (2007) that did not pass, but was rather sent to an interim committee for further study. The interim committee did not choose to study it because the bill is wholly unnecessary given the excellent outcomes for Licensed Direct-Entry Midwives (2006, 2007).

This year’s version (SB 93) includes a myriad of restrictions that would exclude a woman from the care of a direct-entry midwife. Some of the exclusions are valid (HIV positive women, premature babies, etc.). Most of them, however, are not. In fact, over 90% of the women who currently choose the care of a direct-entry midwife would no longer be able to do so. I personally “risk out” multiple times.

Among this year’s outrageous guidelines that would cause a woman to be labeled too high risk to give birth at home with a midwife are the following:

  • pulmonary disease (asthma is a pulmonary disease), line 117
  • Group B streptococcus colonization or infection disease (this can be treated safely at home), lines 118 and 119
  • hematological disorder (anemia is a hematological disorder–this can be treated), line 121
  • hypertension (but it doesn’t say what constitutes “high” blood pressure), line 122
  • a family history of a serious genetic disorder that may affect the current pregnancy (whether or not it actually does affect the current pregnancy seems to be irrelevant), line 124
  • a history of neonatal infection, line 125 (One of my newborn’s caught Strep A from my husband who had strep throat at the time of her birth. That’s a “neonatal infection” since she got it as a newborn, yet it had nothing whatsoever to do with where, how, or with whom she was born and is very unlikely to repeat with future babies.)
  • a history of cerclage or incompetent cervix (even if the current pregnancy reaches 37 weeks), line 125
  • a history of an infant below 2,500 grams (5 lbs. 8 oz.) or above 4,500 grams (9 lbs. 14 oz.), lines 125-126 (So if a woman had twins who were small, she would be prevented from having home births with any future babies and any woman who birthed a large baby with no trouble would be forced to go to a hospital.)
  • a history a preterm singleton birth of 36 weeks or less (even if the current pregnancy lasts until 37 weeks), line 126
  • a history of a postpartum hemorrhage requiring transfusion (no matter what the circumstances of the hemorrhage were, no matter that it may not be likely to repeat–what if her doctor decided to manually extract her placenta, causing a massive hemorrhage?), lines 126-127
  • a history of three or more consecutive miscarriages (again, whether or not the current pregnancy lasts until 37 weeks), line 127
  • a miscarriage after 14 weeks, line 128 (What if she got in a car accident? What if her current pregnancy goes to term?)
  • a stillborn, line 128 (What if she experienced complications from common medical interventions? What if it was because the baby had a genetic disorder incompatible with life? What if her current pregnancy is unlikely to be threatened by the previous circumstances? What if the woman would still prefer to give birth at home?)
  • a prior myomectomy, hysterotomy, or c-section, line 129 (So no more vaginal births after cesareans (VBACs). They’re nearly impossible to get in hospitals around here. Home birth was really the least restrictive option. For most women, VBAC poses only slightly more risk to the mother and baby than a vaginal birth without a prior c-section. C-sections carry very significant risks and it should be left to the mother to decide which risks she’s most comfortable assuming. It’s important to note that all of the VBACs attended by Utah Licensed Direct-Entry Midwives have had favorable outcomes.)
  • any condition, disease, or illness that would disqualify a certified nurse midwife, licensed under Chapter 44a, Nurse Midwife Practice Act, from delivering a child (amended), lines 132-133 (Certified Nurse Midwives must practice under the supervision of an obstetrician. The OB gives them permission (or not) to attend certain pregnancies and births. I don’t know of any OBs in the state who would give a CNM permission to attend a home birth. If interpreted this way, this clause automatically prevents direct-entry midwives from attending anyone!)

If any woman manages to qualify under the above restrictions, she’d then be subject to further “screening”. Mandatory consultation with a licensed health care provider is required upon:

  • a threatened miscarriage or miscarriage after 14 weeks, line 202 (Some women may be reassured by a doctor consultation, other women, knowing that there is nothing a doctor could do, may prefer to just wait things out. Under this law, a woman would have no choice.)
  • vaginal bleeding after 13 weeks of gestation, line 203 (Again, some women may want a visit, others may not. What’s particularly difficult is the fact that most doctors would be absolutely hostile and rude toward any woman who was or is planning a home birth.)
  • discovery of maternal age as of the estimated day of conception of more than 35 years, lines 205-206 (Good heavens! You’re over age 35? You’re going to kill your baby!)
  • assorted other conditions that still leave a woman no choice in her own health care decisions

Mandatory transfer of patient care before the onset of labor to a physician licensed under Chapter 67, Utah Medical Practice Act, or Chapter 68, Utah Osteopathic Medical Practice Act, is required, upon evidence of:

  • multiple gestations, line 226 (This one really steams me. When you look at home born twins vs. hospital born twins you find a very drastic difference in treatment and outcomes! Home born twins are commonly born at term–many even go a full 40 weeks or longer! Home born twins are generally larger–some are even 8 or 9 lbs. each! Home born twins are born vaginally. Hospital born twins are commonly born prematurely. Sometimes this happens spontaneously, other times mothers are induced or c-sectioned early, often without a clear medical indication. This results in premature babies that could have been born as healthy full-term infants. Hospital born twins are usually much smaller as well, and suffer the complications small and early babies are subject to. Given this information, I would not at all feel comfortable giving birth in a hospital with twins unless they came prematurely on their own.)
  • known or suspected Group B streptococcus colonization or infection, line 227 (Suspected? Suspected?! That’s every single woman on the planet! This line here is another that would eliminate every woman! Also, group B strep during pregnancy and birth can be safely monitored and treated at home.)
  • intrauterine growth restriction, which includes a fundal height that measures more than three centimeters less than the weeks of gestation, lines 228-229 (This restriction does not allow for variations in a mother’s shape or how she carries her babies. I’ve measured more than 3 cm small and gone on to give birth to a baby over 7 lbs. Closer monitoring may be indicated, but mandatory transfer is certainly not!)
  • suspected macrosomia, which includes a fundal height measuring more than three centimeters greater than the weeks of gestation, lines 232-233 (Again, this doesn’t factor in a mother’s shape.)

Mandatory transfer of care during labor and an immediate transfer in the manner specifically set forth in Subsection (4)(a), (b), or (c) is required upon evidence of:

  • a membrane rupture of more than 18 hours, line 239 (There is an increased risk of infection after a woman’s water has broken. However, if precautions are taken to reduce the risk–no vaginal exams, for one–and a woman is monitored to make sure she doesn’t exhibit signs of infection such as a fever, there is no logical reason why to give her a time limit of any sort. If mother and baby are both doing well, there is no reason to intervene. A mandatory transfer would place this mother in a germ-ridden hospital environment where care providers are inclined to perform multiple, infection-introducing vaginal exams and recommend significantly risky induction medications or cesarean surgery. That’s not safer than staying home when there’s no problem.)
  • breech or other inappropriate fetal presence, line 241 (One can only guess at what’s meant by “inappropriate fetal presence”, but vaginal breech when attended by an experienced attendant for a screened population is at least as safe as cesarean birth. A mandatory transfer for a breech baby would mean major abdominal surgery for the mother, whether or not she finds the risks of a c-section preferable to the risks of a vaginal breech birth. Of course, this c-section would then forevermore prevent her from having a home birth with a future baby.)
  • failure to deliver after three hours of pushing, line 246 (Time limits and birth should have nothing to do with each other. Birth takes as long as it takes. This length of pushing is unusual, but if a woman wants to keep going and she and her baby are both fine, then she should keep on pushing!)

And there you have it. I have purposely left out conditions that would appropriately be transfered. The situations I have included are the ones that may indicate closer monitoring but should not automatically risk a woman out of receiving care from a direct-entry midwife.

If you would like to help and you live in Utah, please join the Utah Friends of Midwives yahoo group for information on how you can help. We need hospital birthers, too!

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8 Responses to “Utah Medical Association is trying to eliminate home birth again.”

  1. Heidi Says:

    Hi Laura –
    I didn’t know you had a blog! Good job! Succinct and useful information.

    PS – hope the elbow is healing well!

  2. birthnaturally Says:

    Thanks, Heidi! 🙂 Elbow is doing ok. I’ll know more next week.

  3. lisa Barrett Says:

    nice article.

  4. Betsy Melancon CPM Says:

    The midwives in Southern Nevada will be watching your progress with great interest. I personally thought the 2005 law was very workable. The medical association certainly doesn’t restrict c-sections to ‘high risk’ women. Isn’t performing surgery on a healthy person the definition of mal-practice? The discussion of licensing comes up for us regularly with most midwives against it. My feeling is the legal battles just put midwifery more in the public’s eye, increasing awareness and support. Don’t give up the fight, you’re making history.

  5. Ray Thrush Says:

    Hello. This is kind of an “unconventional” question , but have other visitors asked you how get the menu bar to look like you’ve got it? I also have a blog and am really looking to alter around the theme, however am scared to death to mess with it for fear of the search engines punishing me. I am very new to all of this …so i am just not positive exactly how to try to to it all yet. I’ll just keep working on it one day at a time Thanks for any help you can offer here.

    • Laura Says:

      I think it’s simply a matter of the theme I chose for the blog. I don’t think I changed it (I don’t really know how)…. The theme name is Kubrick by Michael Heilemann (the default theme). It has a custom header.

  6. Kirsten Says:

    I know I’m years behind in finding out about this, but I have had a hard time finding what the resolution to this bill was. Does a woman with hypertension no longer have the option of having a homebirth? What if she is on medication for it and it is manageable? Thanks in advance for any information you can point me toward!

    • Laura Says:

      Hi, Kirsten! We lost home birth with licensed midwives for known twins, known breeches, and for moms with more than 2 prior c-sections or if the c-section incision was anything other than low and transverse. Other medical “conditions” are categorized as mandatory consults or transfers.

      This was my update at the time.

      Here are what I believe are the current rules for licensed direct-entry midwives. For hypertension it says (under “may require transfer):

      severe hypertension defined as a sustained diastolic blood pressure of greater than 110 mm or a systolic pressure of greater than 160 mm

      And here, under “mandatory transfer”:

      a systolic pressure greater than 160 mm or a diastolic pressure greater than
      110 mm in two readings at least six hours apart, or 3+ to 4+ proteinurea, or greater than
      5 gms of protein in a 24 hour urine collection; or
      (B) a systolic pressure greater than 140 mm or a diastolic pressure greater than
      90 mm in two readings at least six hours apart, at least 1+ proteinurea, and one or more
      of the following:
      (1) epigastric pain;
      (2) headache;
      (3) visual disturbances; or decreased fetal movement;
      (ii) eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome
      (HELLP);
      (iii) documented platelet count less than 75,000 platelets per mm3 of blood;
      (iv) placenta previa after 27.0 weeks gestation;
      (v) confirmed ectopic pregnancy;
      (vi) severe psychiatric illness non-responsive to treatment;
      (vii) human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome

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