Licensed California midwives push for more responsibility
For her second child, Angie Rivera chose to give birth not at a hospital, but at the Community Birth Center on West Florence Avenue in South Los Angeles. Angie’s husband, Joseph O’Day and her midwife, Racha Tahani Lawler, were by her side for the two-day experience.
In fact, they were both there for both children’s births, as licensed midwife Lawler was Rivera’s midwife for her first baby, too.
The “licensed” distinction is an important one. Lawler and California’s other 300 or so licensed midwives get their certification from the same agency that oversees doctors: the Medical Board of California. They are required to complete three years at a board-certified midwifery school and pass exams. They are trained to assist women with low-risk, normal births between 37 and 42 weeks of pregnancy.
In 2012, California’s licensed midwives helped deliver 2,300 babies.
But these midwives are mired in a Catch-22. They are legally obligated to be supervised by physicians. If a doctor supervises a licensed midwife, however, the doctor runs the risk of losing liability insurance.
“So for the most part, they’re sort of on their own, and that’s a real shame,” said Folsom-based OB/GYN Dr. Ruth Haskins. Haskins has a unique relationship with licensed midwives, having served on the Medical Board’s Midwifery Advisory Council for eight years. “And so these are licensed professionals trying to do the best they can, but they don’t have a shoulder to lean on.”
If licensed midwives could collaborate with doctors, said Haskins, women could get the intimacy of the home birth they seek and the specialized expertise of obstetric medical care.
This lack of supervision also creates other problems. Licensed midwives often have difficulty ordering and receiving lab tests for their clients or getting prescriptions filled.
And Medi-Cal, California’s version of Medicaid, does not issue reimbursement for licensed midwives’ services, so low-income women don’t really have the option of seeing them.
“If they are required by law to be supervised, then the supervisor needs to be listed on the application,” said Shannon Smith-Crowley, lobbyist for the American Congress of Obstetricians and Gynecologists (ACOG), the organization representing obstetrician-gynecologists. “So you see the problem if you can’t get a physician supervisor, then, you know, de facto you can’t be Medi-Cal.”
To deal with this problem, licensed midwife Lawler offers her services on a sliding scale.
Most of these challenges stem from the liability quandary. But, midwives and lawmakers working with ACOG-sponsored legislation hope a new bill, AB 1308, could change things.
“The best possible outcome is if we could really build that relationship between our licensed midwives and physicians,” said Assemblywoman Susan Bonilla (D-Concord), who wrote the bill, “where we could have a situation where a mother would have her charts, her medical history, all available in preparation for that very slight chance that something, you know, might happen, that she might need that medical intervention.”
Indeed, OB/GYN Ruth Haskins says if women are going to give birth outside the hospital, they should be as safe as possible.
“The ideal situation is that the liability carriers come on board and recognize that if they cover physicians who are nervy enough and astute enough and kind enough to supervise licensed midwives, it will decrease the overall liability that they will end up having to cover,” she said. “The highest liability patient is the one who just pops into the hospital and has never been seen by anybody before and you don’t know her.”
During Rivera’s birth, her baby got stuck on what’s called a cervical lip. She refused the solutions Lawler offered, which included manually pushing the cervix over the baby’s head like a turtleneck.
Instead, Rivera started asking to go to the hospital.
“I just felt like, I don’t know, like I was gonna die.... like I was going to pass out or something,” Rivera recalled.
“She was exhausted,” O’Day added. “You know, it had been what, 28, 29 hours at that point.”
In addition to keeping mom and baby safe, licensed midwives like Lawler say their goal is to empower mothers throughout pregnancy and birth. For her, that means letting them make the decisions whenever possible. So, even though Rivera’s and her baby’s vitals were stable, Lawler did eventually call for an ambulance.
“Some people think I just sit in the corner and burn sage and hum in Birkenstocks,” Lawler said. “My job when they come to me is to create a relationship with them so that they’re OK with me being there and then to keep them safe and to keep their babies safe.”
But, some doctors simply do not trust out-of-hospital births.
“You know, people have come in with dead babies,” said OB/GYN Eve Yalom, who treats high-risk pregnancies in Berkeley. “Not just once. More than once. More than a few times.”
Yalom said she would not work with licensed midwives, even if the supervision regulation is lifted. However, she is their backup doctor by default because she would not turn someone away in a crisis.
“But what you really want is to have a healthy mom and a healthy baby,” she said, adding, “Hospital deliveries are safer for mother and baby.”
That’s the official word from ACOG, the OB/GYN group, too -- that the safest place to give birth is in a hospital, which is where nearly all of California’s half million babies are born each year. But ACOG’s own Shannon Smith-Crowley says childbirth can be just as safe for the women who give birth at home.
“All of the data say the home birth setting can be safe for appropriate women, as safe as a hospital, when the care is integrated,” Smith-Crowley said. “So that means when the midwife is working with the physician and the rest of the health care delivery system.”
After months of negotiation, the ACOG-sponsored bill has been amended to cover many of the issues both midwives and doctors have been struggling over for years.
If the bill passes, it will remove barriers for midwives trying to get supplies and medications for their clients. It will define normal birth, making it illegal for midwives to manage high risk births such as twins and babies who are positioned with their head up instead of down.
The biggest change is that it will eliminate the requirement for physician supervision. The bill would require midwives to refer or transfer a client to a physician if the woman’s condition “deviates from normal at any point in the pregnancy, childbirth or postpartum care.”
However, there is still a major issue that the bill does not resolve: What will liability look like for doctors who decide to work with licensed midwives and their clients? The bill does not give additional protections to physicians who choose this path. If a woman comes in to the hospital late in labor and something goes wrong, it could be seen as the physician’s fault.
In South Los Angeles, the paramedics stood in the hallway, while Lawler coached Rivera through the end of her labor. The baby boy decided to be born right then and there, on the bed, in the back bedroom at the birth center. Not in the ambulance or at the hospital.
The baby boy, nicknamed Wolfie, was 7 pounds and 10 ounces and healthy. River and O’Day said they would do it all over again.
“We already did it twice, right,” O’Day said. “Honestly, I just trusted Racha, ‘cause you know, I’ve been at two births and she’s been at a lot more than that.”
If AB 1308 passes it will define the parameters of a normal birth, make it illegal for midwives to manage high risk births, and will eliminate the requirement that midwives have to have a physician's supervision. For the latest version of the bill including analysis you can find it at California Legislative Information.