House Bill Requires Midwives to Be Licensed in Oregon

Rep. Alissa Keny-Guyer said requiring the license is a first step toward including home births in the Oregon Health Plan

Editor's Note: This article has been corrected from an earlier version.

March 19, 2013 — At a House Health Committee hearing last week, Margarita Mareboina held up pictures of her son, who died during labor after a botched delivery by unlicensed midwives in 2011. The baby was covered in meconium, the viscous, tar-like stools of a newborn’s first bowel movement.

She said the unlicensed midwives told her that her pregnancy was low-risk, but she also didn’t trust them in hindsight and an obstetrician may have disagreed.

“They failed me and my son,” Mareboina said. “I delivered two days after my water broke. My son was perfectly healthy. He died a preventable death.”

House Bill 2997, heard Friday before the House Health Committee, would require direct-entry midwives be licensed with the State Board of Direct Entry Midwifery. The board would have the power to set rules, investigate and discipline midwives, including the power to impose civil penalties.

HB 2997 is backed by two very different mothers with two very different political viewpoints — Rep. Alissa Keny-Guyer, a liberal Democrat from Portland, and Rep. Julie Parrish, a conservative Republican from West Linn.

“All of my children were born in hospitals with full-on drugs with cake at the end delivered by folks from the cafeteria. Birthing babies in my living room was probably not high on my to-do list,” said Parrish, while Keny-Guyer had a decidedly different perspective:

“For the majority I’d say, myself included, home births with qualified midwives have had the high quality, patient-centered, lower cost healthcare outside a hospital setting which aligns with the direction of our healthcare transformation,” Keny-Guyer said.

“The practice of home birth has been inconsistent and some families have suffered devastating losses,” she added, while Parrish said she wanted to do what she could to help protect mothers who choose home births. Part of the problem is that some advertised midwives have a high level of professional accountability, while others practice without any qualifications.

Keny-Guyer had hired certified nurse midwives, who double as registered nurses and work in conjunction with a hospital or birth center and are required to be licensed.

HB 2997 affects direct-entry midwives, who can be educated through self-study, apprenticeship or a formal academic program. Currently, they must be involved in delivering at least 50 babies and meet other requirements before becoming licensed by the state, but licensing is entirely voluntary and many are unlicensed.

Judith Rooks, a midwife, epidemiologist and author of “Midwifery and Childbirth in America,” cited statistics showing last year in Oregon, direct-entry midwives attended 7 infant deaths out of 1,200 births — a rate 8 times higher than in Oregon hospitals, where there were 25 neonatal deaths out of 40,000.

“Oregon needs more direct-entry midwives,” Rooks said. “Many are excellent, but the floor is not high enough, the practice of these midwives is not safe enough.”

The new mandatory license requires that direct-entry midwives, among other things complete written and oral examinations; become certified in cardiopulmonary resuscitation for infants and adults; participate in a minimum of 25 assisted deliveries, 100 prenatal care visits and 25 newborn examinations.

The bill also requires licensure for any midwife seeking reimbursement from the Oregon Health Plan. As reported earlier in The Lund Report, coordinated care organizations — which now deliver healthcare to Medicaid patients — have been reluctant to compensate for home births, largely because so many midwives are unlicensed.

“I want to work really hard to have home midwifery become part of the CCO program,” Keny-Guyer had told The Lund Report. She said Oregon Health Authority Director Bruce Goldberg wanted the licensing bill to go through before they reopen the discussion of midwives in CCOs.

The law does leave exceptions for licensing midwives who practice as part of a religion or ethnic culture, and if the patient signs a waiver of informed consent.

Several people spoke against this exemption at the hearing, including Heather Johnson, a doula and midwifery student at Oregon Health & Science University: “I ask that you first take into consideration babies and mothers first,” said Johnson, who was born at home but had a relative who died in a delivery with an unlicensed midwife.

But Dr. Duncan Neilson, the chief of women’s services at Legacy Health System, said it would be impossible to enforce certain recent immigrant groups or Russian Old Believers who keep to themselves.

“When a woman becomes pregnant, she will deliver,” said Neilson, an OB-GYN who sat on the task force that crafted HB 2997. “We can only regulate the people who are publicly listed as midwives.”

He told The Lund Report after the hearing that he trusted the Board of Direct Entry Midwifery to exclude midwives from the exemption if they had no legitimate cultural or religious excuse to avoid licensure.

The large majority of those testifying on HB 2997 supported licensure, but the bill was not without its critics.

Kaire Downin said women were turning to home births because of the high rate of Cesarean births at hospitals, and said that licensing midwives was not the answer to reducing infant mortalities.

“Women have the right to choose and they also have the responsibilities to make sure that the person they choose is adequately trained and experienced in what they’re looking for,” Downin said.

Linda Bennett told Rep. Mitch Greenlick that he was coming through on his promise to “criminalize” unlicensed midwifery by supporting the bill. Bennett told the committee she was arrested for acting as a midwife without a license in California, and others will do the same in Oregon if HB 2997 passes.

Greenlick denied “criminalizing” midwifery was his intent.

One unstated reason for the opposition to licensure is the high fees associated with becoming certified. But Keny-Guyer said fees should come down as more midwives pay into the pool that pays the licensing board for its work.

HB 2997 was not called for a vote, but it is expected to pass later this session.

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Thanks for the article. One correction, however. In paragraph 10, you mention certified professional midwives (CPM's) who "double as registered nurses..." CPM's are not required to be registered nurses, although some are. I think you're referring here to certified nurse midwives, or CNM's. CNM's are required to have previous training as RN's and do their midwifery training at the master's or doctorate levels. They are licensed in all 50 states and can work in hospitals, birth centers or attend home births. I've never heard of a CPM having hospital privileges.

Just to clear something up, Keny-Guyer used Certified NURSE Midwives. This is part of the problem. Certified PROFESSIONAL midwives were not required to have even a high school diploma until last year, when NARM (the licensing body for CPMs) upped the requirement. Certified NURSE midwives are nurses with a minimum of a master's degree. Very confusing to the consumer. Some would argue this is purposeful on the part of the creators of the CPM license. Direct entry midwives in Oregon are currently required to pass the NARM exam and get a CPM to qualify for the voluntary license. It is these midwives that have the terrible outcomes to which Judith Rooks is referring.

Thank you for your article Mr. Gray. Would you kindly make the following changes? My midwife, Darby Partner of Eugene, told me that my "pregnancy" was low-risk. My Son Shahzad died a "preventable" death. Thank you, Margarita Mareboina

I'm a midwife in Oregon. I am a midwifery educator; a national and international lecturer on childbirth issues; retired Licensed Midwife, Certified Practical Midwife, Certified Midwife, and a former member of the Board of Licensed Direct Entry Midwifery. I want to correct some information supplied in the article, and put into perspective some of the data presented. But first, I would like to express my condolences to Ms Mareboina for the loss of her baby. I can't comment on her birth because I wasn't there and don't know the circumstances, but the death of a baby is always a tragic event and I extend my sympathies, and join with all in hoping to avoid future losses whenever possible. Sometimes, quick access to emergency care would have made a difference in a birth outcome: other times these sad losses are not preventable and would have occurred in any location. The duty of a homebirth midwife (and her training) is to assess these situations and transfer for needed medical care. In general, midwives in Oregon do a good job of providing private support for women who desire homebirth; keeping alert to potential problems and remedying them when possible; and quickly responding to emergencies or transporting for medical care. Now for the corrections. 1. The article states “Oregon and Utah are the only two states that still allow direct-entry midwives to practice without a license”. This is not correct. Most states in the US do not have mandatory licensing for midwives. According to the latest statistics from the Midwives Alliance of North America, currently only eighteen states license midwives. Six states certify, register, or permit them. Ten states prohibit midwives completely (some of them even prohibit Nurse-Midwives). Thirteen states do not even address the issue of midwives, and midwifery is legal and unrestricted in all of these states. Most states with mandatory licensing still permit means for non-licensed midwives to practice with restrictions – as does our neighboring state of Washington. Oregon and Utah do have a 'unique license' though, because in these two states the intent of licensure is “ only for purposes of reimbursement under medical assistance programs” (I am quoting directly from the statutes). In these two states Midwifery is specifically termed “legal”, so a license had to be created to allow midwives to receive Medicaid insurance payments. The Oregon Direct-Entry Midwife License was written in 1993 before the implementation of the Oregon Health Plan, at a time medicaid-fee-for-service obstetrics (the most expensive care) was costing the state an extraordinary amount of money. Licensing would permit midwives to attend births for women who choose them, at a small fraction of the fee-for-service rate of hospital and obstetric care. Because Oregon had tracked birth outcome for several decades both by location and by 'type of attendant', and the statistics for midwife-attended birth were good ( “Outcomes have generally been positive for out-of-hospital births” -- according to the Dept of Vital Records), this was a reasonable cost-saving decision. 2. The article quotes Ms. Judith Rooks as stating that in “Oregon hospitals,.. there were 25 neonatal deaths out of 40,000” births. This statement should be explained. Ms Rooks is referring to the loss of a baby during the time of birth. The hospital neonatal mortality rate for term babies was stated as being 2.1 per thousand for that year (an unusually low number). I wish it could be accurately stated that only 25 term babies died out of 40,000 births, but sadly this is not true; there were actually 84. The mortality rate in the US may be close to the achievable minimum in preventable deaths, but we do want to continue to work to lower it! 3. 'The article says that Ms. Rooks “cited statistics showing last year in Oregon, direct-entry midwives attended 7 infant deaths out of 1,200 births — a rate 8 times higher than in Oregon hospitals” . I have the report which Ms Rooks was reading from and there are some errors in this article. The report is “ Preliminary Data on Oregon Birth Outcomes, by Planned Birth Place and Attendant Pursuant to: HB 2380 (2011)” No authors are listed, but it is from the Public Health Division Directors Office . There is no quotation in this report of a death rate 8 times higher than hospital, and there were not 7 “infant” deaths. Three of these losses occurred in the days or weeks before labor ever began; just four babies were lost after birth. The report lists the term mortality rate of hospital born babies as being 2.1 per thousand, and the out-of-hospital rate as 4 per thousand. At no point does the report ever state that the homebirth loss rate was 8 times higher than the hospital loss rate. That report states there were 1,995 planned out of hospital births (home or birth center): that midwives attended 1235 of them (at least a third of these would have been in a Birth Centers. The term Out-of-hospital may mean Birth Center, Clinic, or home.) Licensed midwives attended 1040 births, and nonlicensed midwives attended 195. The rate of lost babies was statistically identical for both LDEMs and nonlicensed midwives. Based upon this report from a single year or statistics, licensed midwives and non-licensed have the same birth outcome, and there would be nothing gained from mandatory licensure. Statistics are difficult things. They can be used to demonstrate trends and facts, but often can cloud an issue. A different way of looking at this data collection would be to include only the four losses which occurred during labor or birth, because this the midwife's role. This intrapartum loss would calculate out to 3.3 per thousand, which is closer to the hospital statistics of 2.1 per thousand. It is difficult to compare rates when the number of events is very small: when the rates are close: and when there is only single year of statistics. When dealing with low numbers, even one event can skew the rates severely and result in inaccurate conclusions of the data. To avoid error, most studies of this size will gather years of data before publishing. The rate of hospital loss in this data collection was unusually low that year. Oregon rates are usually closer to 3 per thousand (For example, in 2009, the last year of available data, the rate of loss at term in Oregon hospitals was 3.2 per thousand.). The rate of loss in the homebirth group was also unusually high due to two losses at twin births (generally considered higher risk and seldom attempted at home). Subtracting just these two from the neonatal loss would bring the rate to 1.6 per thousand. If this had been a more typical year, the rates of home and hospital birth would likely be closer, and almost identical as they have been in most years. About the proposed bill: I have dedicated these recent years to teaching midwives to increase the safety of out-of-hospital birth by recognizing dangerous situations, assessing risks and appropriate emergency response. For the greatest safety in childbirth, the lines of communication between birth attendants and medical care providers must be open so transfer for care can be swift, and without obstacles or barriers. Currently midwifery is legal in Oregon, and women are able to choose their midwives from a wide variety of backgrounds (of course, every midwife must fully disclose her training and experience). Women can choose between LDEMs, or CPMs or CMs or CNMs, or midwives with other credentials training and . Families now have easy access to hospitals, and midwives now have easy access to medical providers for consultation and testing. The experience of childbirth is a deeply personal, emotional, and-- for many people - a spiritual event. Natural birth is a complex interplay of physical conditions, emotions, and hormonal response. Many women feel that they can't labor well in hospital, and they require the privacy of their own homes and the people they choose to attend them. Their decisions should be respected. A woman's personal decisions about reproduction are a basic human right and are protected in most nations. I think the state of Oregon has a good law right now. It fits in well with the majority of US states. Most states to not license midwives, but allow women the freedom and responsibility to make their own educated choices about their attendant in childbirth. Most of those states who do license midwives, provide exemptions so “Traditional Midwives” or Community Midwives can continue to serve. If licensing is made mandatory it will create a new class of criminal; both the unlicensed midwives, and the women who choose them. If midwives become criminalized, Oregon will lose many of its most experienced midwives. In rural areas, women will be unable to find legal midwives and will lose the attendants who have served them for many years. Very few of them will chose to go to hospitals: they will give birth at home without Attendants if they are unable to use a Licensed Midwife, or to persuade their midwives to attend them in secret and illegally. Homebirth will go underground, the worst situation possible because it will delay necessary access for emergency care! Out-of-hospital birth can be made safer, but only if it remains legal!

Actually, Margarita Mareboina's OB/Gyn's notes and charts showed her to be low-risk, which I agreed on when I received and reviewed the chart. In a homebirth setting, the client is required to reveal all health history so that the midwife can make the decision about a potential client's low or high risk status. If a client chooses not to fully reveal her health history then that is the only way a high-risk mother could be a part of a midiwfery homebirth practice. I only accept low-risk mothers in my homebirth practice. Margarita chose to transfer care to me because she wanted a homebirth and also because she did not want to be induced. She chose to hire me, after a full informed consent of my education and experience. Margarita received excellent care by myself and my assistant, all of which followed the Licensed Midwife protocols of Oregon.

Darby Partner of Eugene- I can't beleive youh have the nerve to post confidential patient info on this website, I have just filed a complaint with the DA's office in Eugene. Hopefully they will investigate this matter.