PEBB Looks into High Risk Births

The board, which represents state employees, could decide the role of licensed direct entry midwives on Sept. 21
September 16, 2010 -- Midwives are back in the hot seat again. This time the Public Employees’ Benefit Board will decide what criteria should be used to determine whether charges for a birth attended by a midwife should be paid by Providence Health Plans, the statewide health plan.   
On Sept. 21, the board intends to review criteria developed by the medical staff at Providence.  
“We shouldn’t develop criteria out of a blank slate,” said Peter Callero, a professor in the department of sociology at Western Oregon University who represents non-management employees on the board. “My hope is that we’ll discuss this with the licensed midwives and come up with reasonable clinical policies that are fair.” 
Since 1993, an administrative rule setting process has determined such criteria. “An insurance company setting practice criteria would go directly against the governor-mandated mission of the Board of Direct Entry Midwifery,” asserted Christine Olsen, a research associate at Oregon State University and a founding member of PEBB Members for Maternity Care Choice. “It’s my personal belief that these issues should be left to the experts, which is the Midwifery Board. I believe PEBB should follow licensing guidelines set by the Oregon Health Licensing Agency.”  
Her organization intends to ask PEBB to hold off making a decision until the Midwifery Board has had an opportunity to update those rules. Those rules are very explicit, said Olsen, and only allow midwives to care for mothers when there isn’t an absolute risk to the mother, and they dictate when a midwife must transfer care to a physician.  On Sept. 13, the Midwifery Board held a meeting to discuss those rules.
The Midwifery Board reviews those rules periodically, to make certain they are supported by evidence, Olsen said. That board is comprised of four licensed direct entry midwives, two certified nurse midwives, one obstetrician and a public member.
“I’m surprised the (PEBB) board would take on setting criteria without any expertise,” said Melissa Cheyney, who has a PhD in medical anthropology and chairs the Midwifery Board. “I hope they know what they are getting into. For an insurance company to take on setting criteria for determining what is high risk is a problematic and slippery slope.”
Cheyney knows what she’s talking about. Over the last 10 months she, along with a board committee, has spent hundreds of hours scouring literature, hearing expert testimony from specialists, listening to public comment and reading letters from concerned citizens.
“We’re trying to balance the literature and conflicting viewpoints with a woman’s right to choose,” she explained. “As soon as there was the slightest rumor that we might make changes (to the administrative rules), we were overrun with letters from consumers begging us to leave a woman’s right to choose (home birth or hospital birth).”
Last spring, PEBB Members for Maternity Care Choice successfully rallied to restore coverage of services provided by licensed direct entry midwives under the Providence Health System statewide plan.


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Thank you for covering this issue - I am a PEBB dependent member who participated in efforts to restore coverage. I agree with Olsen: "...these issues should be left to the experts, which is the Midwifery Board. I believe PEBB should follow licensing guidelines set by the Oregon Health Licensing Agency.”

Melissa Cheyney has a serious conflict of interest. In addition to her role as charir of the Board of Direct Entry Midwifery, she is also Director of Research for the Midwives Alliance of North America (MANA) the group that represents direct entry (non nurse) midwives. In her role as the Director of Research, she presides over the project that has collected detailed information on approximately 20,000 homebirths since 2001, the largest existing database of homebirths. Cheyney refuses to release the neonatal and maternal death rates for births presided over by licensed midwives. There is no moral, ethical or legal justification for hiding these death rates from the general public. PEBB should demand access to this data. It is extremely suspicious that Cheyney and MANA refuse to release this data to the general public and raises the possibility that Cheyney is aware that direct entry midwives have unacceptable neonatal death rates, but is trying to prevent American women (and their insurers) from finding out the truth. Amy Tuteur, MD

It is not unique for a health insurance provider to have requirements that certain kinds of care, be delivered in consultation with certain specialists. There are technical medical situations that are exceptionally high risk when care is given by generalists of various kinds, without appropriate consultants involved. The insurer's legitimate interests include both quality of care for its members, and the avoidance of costly complications that the right help can prevent. Yes, there should be great discretion for patients including pregnant women in choosing whom to trust for their care. But there are issues that carry too high risk for unlimited discretion, when a layperson cannot know all the risks and the expertise of the generalists is known to vary enough to cause well-known risks. As a former practicing family medicine specialist delivering obstetric care, I lived with such limitations of discretion and appreciate the wisdom behind them in many instances--even after three years of residency training and many years of experience delivering babies. As a health plan medical director, I know the cost consequences of failure to obtain appropriate expertise when it's needed---I've seen it.