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News / Opinion
Births, Risks and Rifts:
Midwifery
Less Emotion, More Objectivity Needed to Understand Issues Involved in Midwifery
Note:  In June 2004, the Bend Bulletin published an article, “Training of Midwives Inconsistent,” that raised safety questions related to the level of training and qualifications of “lay” midwives.  The Board of Direct Entry Midwifery felt the article contained several inaccuracies and continued to play into a long-standing “turf battle” over midwives and some medical practitioners—including some doctors and nurse midwives—who favor hospital births.
 
It is the intention of the Oregon Health Licensing Agency (OHLA), and the board, to raise the level of discussion on this issue to a more productive level.  Following is a response and clarification of the issues raised in the article.  We welcome comments on this ongoing issue.

Emotions Run High in Debate
There may not be anything more traumatic in the human experience than a mother losing a baby during childbirth.  Perhaps that is why emotions run so high in the debate over hospital versus home deliveries.
 
As a state regulatory agency, the Oregon Health Licensing Agency (OHLA) avoids “taking sides” in such debates.  As a consumer protection agency, we are responsible for educating both consumers, licensees and stakeholders while providing an objective voice in the often-contentious issues that swirl among professions with sometimes-overlapping scopes of practice. 
 
The Board of Direct Entry Midwifery is one of multiple volunteer citizen boards and councils that OHLA oversees in licensing and regulationg multiple health and related professions.  While the agency has authority to compel compliance with state law—including imposing civil penalties against practitioners—we often rely on the expertise of board and council members in disciplinary matters, particularly in situations that call for in-depth knowledge of complicated medical procedures.

"Lay" Not the Same as LDM
“Lay” midwife is a common term used to label midwives who are not nurse midwives.  Unfortunately, “lay” connotes a level less than professional or expert, as in “layman’s terms.”  In Oregon, the correct designation of a state-licensed practitioner is “Licensed Direct Entry Midwife” (LDM).
 
The term “lay” is not interchangeable with the LDM title.  What is interesting is that “direct entry” is actually a misnomer in that midwives who qualify for licensure in Oregon are not entering the field directly—they must meet professional standards established in state law that precludes “direct entry” into the field.
 
Midwives who have been certified by the North American Registry of Midwives (NARM)—the nation’s leading certification organization—as a “certified professional midwife” (CPM) may use that title but may not refer to themselves as a licensed direct entry midwife unless they are licensed by the state.

Home or Hospital Birth?
In general, there is distinct disagreement between midwives and some medical practitioners—including certain doctors and nurse midwives—on a number of issues related to how a baby is delivered.
 
The Bulletin article highlights certain “protocols of modern medicine” such as induced labor, epidurals and cesarean sections that midwives quoted say are “intrusive,” but the main issue addressed is home versus hospital births.
 
The crux of the home versus hospital debate is safety.  A retired obstetrician/gynecologist, a certified nurse midwife, and a pediatrician are quoted as having concerns about a midwife’s ability to quickly and effectively respond to, as the article puts it, “childbirth gone awry.”
 
The article paraphrases doctors who say complications in delivery “usually rear their head late and fast,” causing them to “end up picking up the pieces in the emergency room.”
 
However, the article fails to mention state regulations that require licensed midwives to develop emergency transport plans, to determine the level of risk involved for both mother and baby, and to provide the mother with “informed consent” that explains procedures, alternatives and any risks involved.

LDM Standards Consistent
The article paraphrases Bend-area doctors who say that midwives “lack the medical know-how, as well as the equipment,” to deal with complications in childbirth.  Inconsistency in midwives’ training and education is cited as a reason for concern.
 
Licensed midwives in Oregon must meet qualifications set by the State of Oregon and adhere to regulations designed to protect the public.  While there may be various routes to becoming a practicing midwife throughout the United States and world, there is one set of uniform standards for Oregon’s licensed midwives.
 
Whether or not Oregon’s regulatory standards are high enough is questioned, particularly in regards to clinical requirements such as the number of deliveries provided prior to licensure. 
 
However, no alternative to the current requirements was offered by any of those critical of state standards.  These standards aren’t set in stone.  The agency and board welcome involvement in the regulatory process to better protect the health and safety of the public.

Reason Can Help Heal "Rift"
Dr. Peter Howison, a medical doctor who sat on the Board of Direct Entry Midwifery, stated during hearings related to proposed changes to Oregon Administrative Rules (OAR) for midwifery that “there has been a traditional rift, possibly centuries old, between medical doctors and midwives.”
 
OHLA and the board are hopeful that the issues surrounding that “rift” can be addressed in a climate of open-mindedness and collaboration.  That is the intent of the Oregon Revised Statutes (ORS) concerning the make-up of the board, which includes not only three licensed midwives, but also a physician involved in obstetrics, two certified nurse-midwives and a public member.
 
That open-mindedness and collaboration is in danger of being thwarted when subjective generalizations take the place of reasoned discourse. 
 
While the Bulletin article addressed a number of key issues, it could have been improved by more specifics regarding childbirth safety and more objectivity in its use of language.

Birth of a New Day?
From incorporating seemingly biased comments such as “Some midwives don’t even hold a college degree” to editorializing by describing the certification exam of the American College of Nurse-Midwives as “rigorous,” the article loses its power to inform and educate effectively.
 
Several instances of general comments that don’t provide specific statistics but instead send a message that midwives are unsafe dilute the journalistic integrity of the article:
  • “Local doctors say they’ve seen the lives of many mothers and babies put at risk by lay midwives’ care…”

  • “While most births go fine, some have complications…”

  • “I saw a few babies who died…”

  • “…local doctors have seen many mothers’ and infants’ lives endangered by lay midwifery in recent years.”

  • “I’ve seen too many (deliveries) go awry at the end…it’s not a good position to be in.”
How many is the “many” and “most” described?  The article admits that no reliable data is available yet gives the most weight to words of alarm.  Without hard facts, the article becomes a ping-pong battle between professional camps.
 
As we head into the brave new world of health care in the 21st century, let’s agree to disagree but continue to look for ways to find a common ground that not only protects the public but brings the professions closer together in positive collaboration.
 
Call it the birth of a new day in the health care community.