Midwifery Task Force Final Report 12-1.01.08

Georgia Department of Human Resources Division of Public Health Midwifery Task Force Report

December 2008

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Table of Contents

Introduction and background Purpose Task Force Members Task Force Activities Pros and Cons Recommendations Appendix

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Introduction and Background During the 2006 Georgia General Assembly, House Resolution 1341, sponsored by Representative Stephanie Stuckey Benfield and Senator “Able” Mabel Thomas called for a study committee on Direct Entry Midwifery in Georgia. The study committee, co-chaired by Representative Benfield and Senator Thomas, produced the report, The House Study Committee on Direct Entry Midwifery, Report of the Committee, March 2007. Based on this report, the Department of Human Resources (DHR), Division of Public Health, formed a Midwifery Task Force to review direct entry midwifery in Georgia. Purpose The purpose of the Division of the Public Health Midwifery Task Force was to: 1. Review the recommendations contained in the document, House Study Committee on Direct Entry Midwifery, Report of the Committee, March 2007, House Research Committee Services Office, Georgia General Assembly. 2. Consider the pros and cons of revising the DHR rules on lay midwives to allow for recognition and licensure of Certified Professional Midwives (CPMs) in Georgia. 3. Hear testimony provided by those with expertise relative to midwifery. 4. Submit a written report with recommendations to the Director, Division of Public Health by December 29, 2008. Task Force Members • Chairperson, Jacqueline Grant, MD, MPA, MPH •

Representative Stephanie Stuckey Benfield

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Susan P. Ayers, RN, MPH

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Jane Blackwell, CNM, DSCN

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Schley Gatewood, MD

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J. Larry Boss, MD

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Debbie Pulley, CPM

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Elizabeth Sharp, RN, CNM, DrPH

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Rick Ward, CAE

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Irma Works

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Jane Mashburn, RN, CNM

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Task Force Activities • The Task Force met on October 23, 2008 and November 19, 2008 in Atlanta, Georgia. The agendas and minutes of these meetings may be found in the appendix. • The Task Force heard presentations and/or reviewed information from the following individuals and/or organizations: 1. Andrew Helfgott, MD, MHA, FACOG 2. Claire Westdahl, RN, CNM, MPH, FACNM 3. Claudia Conn, CPM 4. Debbie Sapp, CBE, CLC, non-practicing DEM 5. Fay Brown, Executive Director, Georgia Academy of Family Physicians 6. Jennifer Fargár 7. George Bugg, MD, FAAP 8. Debbie Pulley, CPM 9. Nancy Beland, RN, CNM, Savannah Birthing Center 10. Irma Works, M&I Council 11. Richard Wheat, Vital Records •

The Task Force reviewed multiple documents and materials relevant to midwifery. A list of materials and handouts may be found in the appendix.

Pros and Cons In keeping with the charge to the Task Force, members reviewed the document, Midwifery Task Force Pros and Cons of DHR Revising Rules on Lay Midwives to Allow for Recognition and Licensure of Certified Professional Midwives. This document was compiled based on the presentations, question/answer period and group discussion during the Midwifery Task Force, held on October 23, 2008 and materials distributed to Task Force members. The Task Force approved the document with one modification. A copy of the approved Pros and Cons may be found in the appendix. Conclusions The Task Force concluded the following: 1. There is a lack of data and understanding regarding the extent and scope of CPM practice. It needs to be clearer as to how CPMs practice (e.g., what criteria do CPMs use for referring clients to physicians who may not be low risk; what is desirable and safe practice in regards to communication, collaboration and consultation with physicians). 2. While the standards and scope of practice for Certified Nurse Midwives (CNMs) is understood and documented, there is a lack of information and clarity regarding CPM practice. There is a sense of trust for how CNMs practice under protocol. There needs to be a similar trust demonstrated for how CPMs practice under protocol.

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3. The lack of collaboration between CPMs and physicians is a major concern. 4. It is premature to proceed with revising any rules until it is clearer as to how CPMs practice and there is demonstrated collaboration between CPMs, physicians and hospitals. Changing rules and laws that don’t work is not effective. Revising the rules would not be the right thing to do and should not be considered before a workable system can be demonstrated. Recommendations 1. Pass the approved list of Pros and Cons to Dr. Ford (see appendix). 2. Develop a DHR funded pilot program (demonstration project) with the following purposes: • Demonstrate collaboration between CPMs and physicians and hospitals • Provide a workable model that includes a structure and network of collaboration • Determine if rules for midwifery need to be changed 3. The demonstration project should include the following: • Physicians who would agree to collaborate with CPMs • Ongoing collaboration by CPMs with physicians and hospitals • Volume of patients served by CPMs • Include all CPMs in the program (most are believed to be practicing in the metro Atlanta area) • Development of a protocol that would describe the specific parameters and details of how this collaborative model involving CPMs, physicians and hospitals would work

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Appendix A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. • • • • • • • • • S. T. U. V.

Agenda –MTF meeting October 23, 2008 Minutes – MTF meeting October 23, 2008 Agenda – MTF meeting November 19, 2008 Minutes – MTF meeting November 19, 2008 List of Task Force Members List of Task Force Presenters CNM Rules Midwifery Code Directions to two Peachtree Street House Study Committee on Direct Midwifery Report, 2007 Parameters for Presenters Practice of Midwifery Rules Pros and Cons of DHR Revising Rules on Lay Midwives Position Statement – American College of Nurse-Midwives Brief History of Lay Midwifery Legislation in Georgia Rules of Department of Human Resources Public Health Chapter 290-5-15 Midwifery Georgia Code – Practice of Midwifery Packet of information provided by Debbie Pulley, CPM including: Traditional Midwife Fact Sheet States with Direct-Entry Midwifery Regulation The Vermont Statutes Online, Title 26: Professions and Occupations, Chapter 85: Midwives Administrative Rules for Midwives Clearinghouse Rule 06-096, State of Wisconsin, Department of Regulation and Licensing 2005 Senate Bill 477, 2005 Wisconsin Act 292 Letters/Memorandums to and from GA DHR, DeKalb County Board of Health and GA Department of Public Health, dated 1963-1985. Rules of Department of Human Resources Public Health, Chapter 290-5-15 Midwifery Immunity clauses. Comments via Chat – MTF meeting October 23, 2008 Comments via e-mail – October – November 2008 Position Statement – Bruce M. LeClair, MD, MPH, FAAFP, President Georgia Academy of Family Physicians Presentations – MTF meeting October 23, 2008

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Georgia Division of Public Health Midwifery Task Force Pros and Cons of DHR Revising Rules on Lay Midwives to Allow for Recognition and Licensure of Certified Professional Midwives (The following list is based on the presentations, question/answer period and the group discussion held at the Midwifery Task Force, held on October 23, 2008 and materials distributed to Task Force members) No. Pros 1 DHR already has the authority to develop midwifery rules.

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The current DHR Midwifery Rules do not coincide with the midwifery statute (O.C.G.A. § 31-26-1 et. seq.). The current DHR Midwifery Rules relate to Certified Nurse Midwives and the midwifery statute relates to lay midwives.

It would legalize a practice that is occurring in Georgia. Home births are considered safe.

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Reviewed and revised by MTF on November 19, 2008

Cons The Georgia DPH is currently downsizing due to significant budget cuts and it lacks the infrastructure, funding and resources to manage the training, licensing and oversight that would be necessary to license CPMs. DHR could repeal both the original law and the current rules, since direct entry midwifery is not consistent with the mission of Public Health. In 1979, DHR stopped certifying lay midwives. In 1991, under Dr. Houser’s leadership, Division Director at the time, emergency rules were approved that only recognized CNM. Dr. Houser intended for the statute to be repealed during the following legislative session, but this did not occur. According to Crandall vs. DHR, “The Court finds that the adoption of the permanent rules and regulations prescribing the minimal educational requirements required for a nurse midwife was well within the authority of the Department of Human Resources to promulgate rules and regulations consistent with the Department’s responsibility to promote public health and welfare, and that the rules adopted bear a legitimate relation to that purpose.” “The State should not move to endorse systems that will increase the risk to mothers and infants. The State has been consistent in it’s move to improve the health of mothers and infants by increasing Medicaid eligibility, promoting regionalized perinatal and neonatal care, and regulating the institutions in which deliveries occur.” George W. Bugg, MD, MPH, FAAP. Overall, prenatal/maternity services are no longer provided in the health departments. There are no data or studies that document the outcomes of home births as being safe.

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CPMs are trained and certified. CPMs have completed an accredited program that is part of a system of education that is recognized by the US Department of Education and they are certified by the North American Registry of Midwives (NARM).

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Recognition of the provision of prenatal care for babies delivered at home, as CPMs could be authorized to sign birth certificates. Create opportunities to develop (require) partnerships with physicians and hospitals. The rate of nosocomial infection is less for home births than compared to births that occur in hospitals.

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Home births are already happening in Georgia and being attended by CPMs and other Direct Entry Midwives. DHR already licenses and monitors EMTs.

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The current average cost for a home birth: Hospital: $7000 (uncomplicated vaginal; extra charge for anesthesia, newborn care and provider) Caesarean Section: $17,000 Home birth with midwife: $3,000 http://www.childbirthconnection.org/pdf.asp? PDFDownload=evidence-based-maternitycare

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Reviewed and revised by MTF on November 19, 2008

“As an epidemiology student, I reviewed some of the medical literature on factors affecting infant mortality. The movement of virtually all deliveries to the hospital setting from the home setting has been responsible for improved maternal and infant survival.” George W. Bugg, MD, MPH, FAAP The amount and type of training that CPMs receive is not considered adequate to handle possible complications that may occur. When complications occur with a home birth, the response to protecting the safety of the baby and the mother can be delayed and inadequate and may result in poor outcome and/or death of mother and/or baby. Some midwives’ fear of prosecution deters them from accompanying mother and baby to hospital if complications occur. CPMs prefer to be autonomous and not to be required to have physician back-up. There are no data to substantiate the rate of nosocomial infection is less for home births compared to births that occur in hospitals. Georgia’s Infant Mortality Rate is already one of the highest in the USA and we cannot afford to risk it getting any higher. The licensing and monitoring of EMTs is consistent with DHR’s mandates, responsibilities and core mission regarding emergency preparedness, including but not limited to the Emergency Support Functions 6 (Mass Care) and 8 (Health and Medical). However, the licensing and monitoring of CPMs is not consistent with the mission, priorities and core mission of DHR-DPH. The assumption is that a home birth with midwife is uncomplicated. Should complications occur during a home birth with a midwife, the costs for transport, hospital treatment of baby and mother, post-partum care and follow up care of baby would increase the cost significantly.

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