January 30, 2013 -- Practitioners of one of medicine’s oldest professions could face new regulation in Oregon after this coming legislative session. And implementation of the Affordable Care Act could bring even more changes – though that remains far from clear. What is certain is that many midwives across the state are worried.
The issues are twofold:
Lawmakers are considering whether to require all Oregon midwives to become licensed – this state and Utah are the only in the U.S. that don’t currently mandate licensing. Legislation could also bring changes to midwife oversight and data gathering.
Oregon’s shift to Coordinated Care Organizations briefly threatened to cut off access to home-birth midwives for many Medicaid recipients in the state. For now, women can still receive Medicaid coverage for midwife care, but the options are limited and could change as the Oregon Health Authority examines the issue.
The number of medical professionals affected is relatively small – about 120 midwives – and they deliver only about 3 percent of the state’s roughly 50,000 births per year. But there’s growing evidence that their personal approach to prenatal care and delivery often results in better outcomes for babies than the more common medical approach to pregnancy. A study of low-income minority women in Washington, D.C., found that 15 percent give birth early – but only 5 percent deliver preterm when working with a midwife.
At the same time, many in Oregon are worried about the quality of care that midwives provide here, especially in the aftermath of several high-profile cases involving infant death or permanent physical damage. And statistics on midwife care in the state are limited.
State Reps. Alyssa Keny-Guyer (D-Portland) and Julie Parrish (R-West Linn) co-sponsoring a bill aimed at bringing some reform to midwifery in Oregon.
“This bill would require mandatory licensing, and it suggests changes to governance in the Oregon Health Licensing Authority,” Keny-Guyer said.
At present, the majority of midwives in the state fall into one of three categories:
Certified nurse-midwifes attend 14 percent of Oregon births. Trained at the master’s degree level to provide a range of healthcare services to women, they must consult or collaborate with physicians. The majority who deliver babies do so in hospitals, though some do attend home births or work from birthing centers.
Licensed direct-entry midwives can be educated through self-study, apprenticeship or a formal academic program, and must be involved in delivering at least 50 babies and meet other requirements before becoming licensed by the state. They attend an estimated 1,200 home births in the state annually.
Unlicensed direct-entry midwives are not regulated by the state, and attend an estimated 240-300 home births in the state each year. Oregon and Utah are the only states that allow unlicensed midwives to practice.
A small number of naturopathic physicians are also licensed as midwives through a separate process. They are not affected by the current debates over Oregon Health Plan coverage or midwife licensing, however.
Keny-Guyer would like to require all direct-entry midwives to become licensed, and then to give these health practitioners additional authority to write rules and investigate concerns.
“Along with that authority are increased expectations -- more responsibility to insure safe birth outcomes … and making sure that based on the best evidence that they are creating scope and scale based on best practices and safe births,” she said.
She acknowledges that some concerns about the bill, still in draft form, are valid. It’s not uncommon for a home-birth midwife to earn $20,000 or $30,000 per year from this work, which makes the $1,200 annual direct-entry licensing fee a big hurdle for some. That fee is also as much as 3-4 times higher than what nurses and doctors have to pay.
But reducing the licensing fee through direct legislation would have a fiscal impact, and would make passing the bill more cumbersome and less likely. Keny-Guyer said she hopes that this issue can be tackled administratively.
“We want to make sure we keep home births a safe, viable option for women who choose them,” she said. “I had a home birth myself, so I feel it’s very important we keep that available.”
Oregon Health Plan and midwives
Even before the passage of federal healthcare reform, the state’s non-nurse midwives struggled to be compensated by the Oregon Health Plan, or Medicaid.
Most pregnant OHP participants historically received prenatal care and delivery through managed care organizations, and they have recently been shifted to community care organizations. Though CCOs employ many certified nurse midwives, it is rare – if not unheard of – for these organizations to offer home births.
Women determined to deliver at home have found ways to have their deliveries covered by OHP, but the system is flawed, said Silke Akerson, president of the Oregon Midwifery Council and a licensed direct-entry midwife at Two Rivers Midwifery in Portland.
Women who wait until their third trimester to apply for OHP can then apply for midwife care, Akerson said. “But deliberately waiting until their third trimester means these low-income women, women that we specifically want covered, are not. It means that women who desire an out-of-hospital birth are not covered by any health insurance for their first and second trimester.”
Accepting these women as patients is also risky for their midwives. A midwife who provides prenatal care throughout a woman’s pregnancy is only compensated by OHP after delivery. If a patient intending to deliver at home must instead go to a hospital, her midwife is not paid by OHP for any care provided over the previous nine months or for that midwife’s role in the delivery process
“That’s a disincentive for midwives to transfer them to the hospital if there’s a complication,” Keny –Guyer said.
“OHA would never characterize the third trimester exemption as a loophole - in fact it's the opposite,” said Karynn Fish, spokeswoman for the Oregon Health Authority. “It is a way to preserve continuity of care for women who become eligible for OHP in their third trimester. In most cases, a woman would have had a relationship with another provider, and we don't want to disrupt that.”
Fish emphasized that women can choose to join the Oregon Health Plan earlier in pregnancy and to receive care from a coordinating care organization.
Of course, doing so would prevent them from pursuing an OHP-compensated home birth with a midwife.
So far, coordinated care organizations have appeared hesitant to hire non-nurse midwives, in part for financial reasons. Direct-entry midwives are not required to carry liability insurance, so hiring an uninsured health care provider would expose the CCOs to big risks if parents sued when something went wrong during delivery.
Keny-Guyer said she is concerned about the current situation, which limits women’s options and leaves midwives at risk of going unpaid.
“The Oregon Health Authority is convening a small group made up of representatives from CCOs and women’s health professionals to help advise the agency on future policies” Fish said.
Akerson is watching carefully.
“I am optimistic about OHP coverage,” she said. “I think it’s going to take continued outcry from consumers, but I think eventually we’ll come to a situation where there’s full pregnancy, birth and postpartum coverage for licensed direct-entry midwives through Medicaid.”
Oregon’s Legislature convenes next Monday, and Keny-Guyer estimates that the Oregon Health Authority’s review of midwife Medicaid coverage will last at least until summer. And, any decisions on that front may not come until after the legislative session concludes.