HOUSE BILL 1056 HEARING
STATE HOUSE, ANNAPOLIS, MARYLAND
15 MARCH 2012
TRANSCRIBED BY: Nikki Williams, Deirdre Elvis-Peterson, Lynette Telford
POC: Nikki Williams,
BEGIN TRANSCRIPT:
CHAIRMAN
DELEGATE
PETER
HAMMEN: House Bill 1056 is titled 'Health Occupations- Midwives. Delegate Kelly.
DEL. KELLY: Thank you Mr. Chairman, members of the committee. I appreciate your time on this incredibly important and time-sensitive issue. House Bill 1056 as amended-and you should have some amendments before you-would lift a ban on Certified Professional Midwives in Maryland. It would establish a registry within the Department of Health and Mental Hygiene for these credentialed midwives, similar to the registry we had before the ban was put in place. It would pull together a workgroup to determine a path toward licensure and regulation for Certified Professional Midwives. Twenty-six other states already do this, with no problems, and it's very important to me--and I think to all the people behind me here--that we find a way to deal with this situation. It is very time-sensitive. I would like to point out that--as I understand it, I just got some amendments from DHMH, and they are interested in supporting this bill with amendments, including some changes to the proposed workgroup. It's unclear to me if the amendments also include lifting the ban, and I think the critical thing we need to talk about here.
There seems to be some consensus that we need to address this issue that is before us. It is important that we deal with this right now, but the best way to move forward in dealing with this is having all the folks at the table. Right now, we can't have that because the Certified Professional Midwives are not able to legally practice in Maryland. They're not able to come to the table without fearing that they are going to be prosecuted for practicing nursing without a license. So we want a workgroup that is going to be able to address these concerns realistically, and in order to do that I really think we need to address the issue of the ban. So that, I think, is the crux of this discussion today. Rightnow, we have Certified Professional Midwives attending births in Maryland, and they're fearful that they will be prosecuted for practicing nursing without a license, and that has happened. The current situation, where CPMs who attend homebirths are isolated from the rest of the medical community, is not in the best interest of pregnant women. I think that makes sense to everybody here. If you have a midwife attending your homebirth, and they're afraid that they're going to be prosecuted if they transfer you to a hospital in case of emergency, that is a public health problem. It's a crisis and we need to deal with it.
On the topic of licensing Certified Professional Midwives, I will tell you that it is, in my opinion, safe. It would save the system money, increase access to qualified providers, and it's the right thing to do. The midwife ban came into place in 1978. There was a law that we passed that basically said that midwives who are not nurses were no longer midwives. [Laughter] Prior to that, they had been licensed directly through DHMH from 1910 to 1978. Prior to that, they weren't licensed at all; people had babies and they used midwives. [Laughter] But after 1978, what happened was, DHMH had an administration bill, and they basically said they wanted a more modern approach to the practice of midwifery, and basically came to us and said that licensing midwives--who were not at the time Certified Professional Midwives, because that credential did not exist--it was too much work. The present law and regulation placed the Department of Health and Mental Hygiene--this is from their letter of support for the 1978 ban--'placed the Department of Health and Mental Hygiene in a position of a school for training lay midwives, for which we are not qualified. ' That was the situation on the ground in 1978. The landscape has changed quite a bit since then, and you'll hear from folks who work with Certified Professional Midwife credentialing, so you can understand about that. But even at the time, in 1978, this was extremely controversial. The Maryland Nurses' Association opposed the ban; they said 'As we all know, sometimes laws have unintended effects,' and I think that is what we have seen here with this ban. We also have in that file from 1978 a letter of opposition from the American College of Nurse Midwives, who said, 'As the individuals most directly affected by this legislation, we were ignored during the drafting of the bill,' and 'We recognize the health of the women of Maryland should be protected while alternative health care is preserved.'
That's the issue at stake here. It's incredibly important. The ban does, in effect, prevent most Maryland women of my generation from being able to access a legal homebirth or birth center birth, and a lot of us are really ticked off about it. We do have a handful of nurse-midwives who can attend homebirths. The number I have is five of the 220 Certified Nurse-Midwives; I believe the Nursing Board has a number that's nine, so there's a little discrepancy there, but I've been able to meet and talk [to] about five. And one remaining [freestanding] birth center. But for most women in Maryland, this choice is not legally accessible. Our outdated law is not stopping women from making this choice, and you have in your packets an article from the Baltimore Sun that appeared in January--January 29--and it quotes about five hundred births--homebirths--in the state of Maryland. The number is increasing and increasing rapidly.
We need to address this situation this year, so I hope that we can do that. The current law is forcing midwives underground, and preventing the state from ensuring they are properly trained and effectively regulated. This is certainly not in Maryland's best interest, from a public health perspective, or a women's rights perspective. In the late 1980s, the Certified Professional Midwife credential was established, and the national trend against banning midwives shifted. States began to recognize and license these midwives, who are specially trained in out-of-hospital births. Now 26 states license them, and Maryland should join them. As I mentioned, I believe it is safe. I believe it will increase access to providers and reduce costs, and I believe it is the right thing to do.
On the point of the fact that it is safe, you have a statement in your packet from the American Public Health Association supporting licensure of Certified Professional Midwives, so you can read the full statement. There have been numerous studies on this issue, and our colleague, Delegate Morhaim, actually contributed one of his Ph.D. students to research this for us. She didn't have a position on this bill, and she still does not, but there's a memo from her in your packet that basically evaluates this giant pile of research, but if you want to look at it, I have it. It says that planned--importantly--planned homebirths for low-risk pregnancies have birth outcomes equal to hospital births, and significantly lower c-section and other intervention rates. So this does help women in many ways, but also bring down costs.
There's another sheet in your packet that talks about something called the Wax paper. There are some other studies out there that you may hear opponents of this type of licensure quoting. It's an important distinction, so I'll take your time to make it. The couple of studies that show that homebirth may be dangerous are actually including in those studies unplanned homebirths. It's a huge, different population . A Certified Professional Midwife helping a woman with a homebirth, who has received prenatal care and is thoughtfully doing this, is obviously a population of folks who are going to have better outcomes. They are the ones who are intended to be covered by this legislation. An accidental homebirth is much more likely to be someone who did not necessarily have prenatal care, is in a difficult situation, someone who our colleague, Delegate Costa, might find as a firefighter and deliver their baby. They were included in this study, so that's why those are bad numbers. So keep that in mind if you hear some opposition. Be skeptical if they are saying that it's more dangerous. We're talking about planned homebirths here.
On the point of it saving money and increasing access to care, I just want to point to this study that was commissioned by the Washington State legislature after they passed their midwives' bill. They did a report; it estimated that spending was reduced on health care by 5.5 million dollars over four years, just from that one percent of women who were choosing midwives, because a midwife-attended birth costs less, and when you bring down your c-section rate, you save money. That's not why I think this bill is incredibly morally important, but it's something that we all think about--the fiscal effect on the state. So I wanted to share that with you.
The most important reason we need to address this situation, and address it this year, is that it is the right thing to do. This is not a typical scope-of-practice battle. It is not ophthalmologists versus optometrists. Giving birth to a child is one of the most important events in most women's lives, and women deserve choices. We cannot have an unnecessary ban infringing on our right to determine how and where we give birth. I would like to note that if you look at the co-sponsors of this bill, it's a diverse group of people who support this legislation. We don't often have reproductive health issues that have this type of bipartisan support. This is something that people all across the state really care about. I think you saw the rally today; they had hundreds of people there coming out to support this bill. Finally, I would just like to say that this is not about whether you would choose a homebirth or birth center birth, it is about protecting the safety of the women who make that choice. With that I'm going to pass it off to my panel.
JEREMY
GALVAN: Thank you Mr. Chairman, Madam Vice Chair, members of the committee. My name is Jeremy Galvan, and I'm the president of Maryland Families for Safe Birth. We are a non-profit, based in Hagerstown/Frederick County area, a consumer-based organization working to legalize Certified Professional Midwives in our state. We have hundreds of volunteers across the state, and as you can see we had quite a few come out today in support of this cause. Our petition has almost four thousand signatures, many of whom you should be seeing very soon, as they were delivered to a large number of your offices today.
In January 2011 my son, Samuel, was born at home. As a career firefighter/paramedic in Frederick County, I obviously had some concerns. My profession teaches me everything is an emergency, and so it took a lot of learning on my part to learn all the facts that go along with this, and after a lot of studies and coming to grips with what exactly a midwife is, I found this to be an absolutely safe option for my family, and I supported my wife 100 percent. This organization is comprised of a very diverse group of people. We have Amish people, we have middle-class, White, Black, Asian--all races, poor populations, wealthy populations. Kathleen Kennedy-Townsend was somebody who has supported it very publicly (homebirth rights). We have delegates who have had homebirths. We have lawyers, doctors. This is an issue that affects everybody. It affects husbands, especially our wives, and we want to make sure that, for their births, they are being as safe as possible.
I want to emphasize to you that HB 1056 is not going to make any effect on the number of homebirths, other than to allow it to keep doing what it's doing. It is going up right now with no regulation, and we believe very strongly that it is going to continue to go up, whether or not we have this as a legal option. Our families are going to continue to have homebirths. The Amish are going to continue to have homebirths. That's not going to change, but what can change, and what you have power over, is you have the ability to make us have safe options, and that's what we're here today to ask for, is a safe option. Our CNMs? We have lots of CNMs in our state, only five are attending homebirths. I have all of their names, I've talked with every one of them, I'm on very good terms with all of them. They all support this legislation (the ones who do homebirth). We have a chart on page eight of the packet that we provided you, which shows vaguely where they are. We did miss one before print, and she's in southern Maryland, so take that into consideration. As Delegate Kelly said, 26 states license these professionals. We are strongly encouraging you to go along with this and help us to have this option as well. I really want to emphasize that birth is a nine- or ten-month process, and so women are pregnant right now. Some of them are in this room. Some of them are using a variety of different midwives. Some of them are using CPMs, nurse-midwives. We want to address the safety of these women right now. We do not want them to be at increased risk because we have to wait another year before we come to grips. But I am very optimistic, and very much looking forward to coming to the table with the other parties that are involved, the Nursing Board, and being able to come to an agreement on what would be the safest way to do this. Thank you for your time.
NICOLE
JOLLEY, CPM: Good afternoon Chairman, Madame Vice Chair, and members of the committee. My name is Nicole Jolley, and I am a Certified Professional Midwife. I am in the District of Colbia, and I am licensed and focus my practice in the State of Virginia. So, I'm a midwife. What does that mean? For me that means I work in partnership with parents during pregnancy. It means that I offer continuous, hands-on support to those parents during labor and birth, and the time immediately following. It means that I provide individualized education and counseling to each family that I work with, and a significant part of that education is dispelling misconceptions about midwifery. Sometimes, a mother will ask me, 'Can I still get an ultrasound?' Yes! Midwives offer everything that is standard within the community, and that means that any screening that you are offered in an OB's office in preparation for a hospital birth is also offered to you by your midwife in preparation for a homebirth. And screening is an ongoing process in pregnancy. Professional Midwives are not only responsible for monitoring a mother's physical wellbeing, but also the psychological and social wellbeing, and should any deviation arise during that time, it's my job to refer a mother to the appropriate healthcare professional. That might be an obstetrician, or an endocrinologist, or a chiropractor, or maybe even a maternal-fetal specialist. But what we see is that the best outcomes happen in communities where these various healthcare professions are integrated, so that's what we're working toward.
Another question I hear a lot is, 'Homebirth? Well, what if something happens?' So I say, 'Like what?' 'Well, what if the mom needs a c-section?' 'Well, then we go to the hospital and get one.' Choosing homebirth does not mean that the hospital ceases to exist. It doesn't preclude you from receiving obstetric care, if that becomes necessary. In fact, my clients and I formulate an emergency care plan at our very first prenatal visit, so we've already reviewed and discussed which hospital is closest, which hospital is preferred, where is the neonatal intensive care unit. Informed consent documents and emergency care plans are a normal part of comprehensive care offered by Professional Midwives, and it's all of these factors together that encompass the midwifery model of care. It's a woman-centered model that has been proven to reduce birth injury, to reduce trauma, and cesarean section. So I encourage you to support particularly the registry component of our bill. Without it, the workgroup would render itself ineffective, and CPMs would still be at risk of prosecution, and in truth, at the end of this process, will be in the very same place that we are today. So I really urge you to consider that aspect, and I just want to extend a thank you for the opportunity to tell you a little bit more about what I do, and that you've decided to turn your attention to this issue.
IDA DARRAGH: Mr. Chairman and Madam Vice Chair and members of the committee, thank you for the opportunity to speak. My name is Ida Darragh, and I am the Director of Testing and the Chair of the Board of the North American Registry of Midwives. That's called NARM, and NARM issues the nationally-accredited credential 'Certified Professional Midwife.' I'm also a CPM, and I've been a licensed midwife by the State of Arkansas for thirty years, so I've had a lot of experience working under licensure and working with national accreditation. As part of my job with NARM, I am the primary contact between NARM and the states that license midwives--the state agencies that oversee their licensure and registration. I have firsthand experience with the success of licensing, or permitting--based on the CPM--and all of the states that currently do that. There are 26 states that allow CPMs to practice legally. Twenty-four have licensure and regulation, and two have a permit system without regulation. Those are working well, too. About half of the states had a local licensure option before the development of the CPM, and about half of them created those licensure programs after the CPM, and those require the full credential in order to be licensed. The earlier states that had their own kind of program--they all took the NARM exam as their state licensure exam, but many still implement their own specific state requirements , or their own evaluation of the training of the midwife. But all of them use the NARM exam to measure the final competencies of the midwives who are practicing. Many of these programs have been in place for 20 to 30 years. No state has terminated their licensure program for CPMs or their licensed direct-entry midwife. No state has had a concern about the outcomes that warranted terminating the program or discontinuing their licensure. That, to me, is one of the strongest statements that can be made for the safety and how well it works in states. Even whether there' s 15 or 20 midwives licensed, or whether there's 80 or 100 midwives licensed, it works well. It saves money for the people, it saves money for the state, and the outcomes are good. Every state is happy with their licensed midwife program.