In a tremendous victory for the mother and babies of Oregon, and a tremendous repudiation of homebirth midwives, Oregon has dramatically tightened the requirements for coverage of homebirth.
In many ways, homebirth midwives led by Melissa Cheyney, brought this on themselves. Their utter contempt for safety requirements of any kind led to their marginalization. Four years ago they were dragging their feet on even obtaining consent for homebirth, now it has been entirely removed from their hands.
Here is the document that sets out the new coverage regulations Health Evidence Review Commission (HERC) Coverage Guidance: Planned Out-of-Hospital Birth.
[pullquote align=”right” color=”#bfad74″]Oregon Medicaid won’t pay for homebirth of breech, twins, VBAC, prolonged rupture of membranes and other conditions that homebirth midwives pretend are “variations of normal.”[/pullquote]
It is a 100 page review that carefully documents the conclusion that homebirth is only appropriate in a restricted set of circumstances.
As a result, Oregon Medicaid will no longer pay for homebirth in the case of breech, twins, VBAC, prolonged rupture of membranes and a whole host of other conditions that homebirth midwives chose to pretend were “variations of normal.”
Why won’t Oregon Medicaid pay for homebirth in those circumstances? Because they dramatically increase the risk of perinatal death. Judith Rooks CNM MPH analyzed the 2012 Oregon homebirth statistics and found that the death rate at planned homebirth with a licensed homebirth midwife was 800% higher than comparable risk hospital birth. Moreover, 6 of the 8 deaths in the homebirth group occurred in women that did not meet the criteria for low risk.
What is especially interesting about the HERC document is that it details an extensive review of the literature … a real review, not the cherry picking of papers and misrepresentation of findings that characterize homebirth advocates’ review of the literature.
The authors also call into question the validity of assessing homebirth safety in the US by citing studies from other countries. The note the differences in midwifery training:
The Netherlands
“The midwifery training is a four year fulltime direct entry education, which eventually leads to a Bachelor’s degree. The total study load is 240 ECTS and equals nearly 6,800 hours of education. Altogether, there are two years of theory, one year of primary care internships, and one year of secondary and tertiary care internships. The internships are spread equally over these four years… They have had an extensive assessment, which selects the best candidates. Around
three times more candidates apply for the course than places are available.”Canada
British Columbia
“All current CMBC approved programs are Canadian four year direct‐entry education programs leading
to a university degree, or bridging programs leading to equivalency.”Ontario
“1. The applicant must have at least one of the following:
A baccalaureate degree in health sciences (midwifery) from a university in Ontario.2. The applicant must:
Have current clinical experience consisting of active practice for at least two years out of the
four years immediately before the date of the application, and
Have attended at least 60 births, of which at least:
- 40 were attended as primary midwife
- 30 were attended as part of the care provided to a woman in accordance with the
principles of continuity of care- 10 were attended in hospital, of which at least five were attended as primary midwife,
and- 10 were attended in a residence or remote clinic or remote birth centre, of which at
least five were attended as primary midwife3. The applicant must have successfully completed the qualifying examination that was set or approved
by the Registration Committee at the time the applicant took the examination.”
As compared to:
North American Registry of Midwives [CPM certification]
There are multiple routes to certification by the NARM, but in general they include a written test, a skills
assessment test, and the following experience requirements:
- Phase 1: Births as an Observer
Ten births in any setting, in any capacity- Phase 2: Clinicals as Assistant under Supervision
Twenty births, 25 prenatal exams, 20 newborn exams, 10 postpartum visits- Phase 3: Clinicals as Primary under Supervision
Twenty births, 75 prenatal visits, 20 newborn exams, and 40 postpartum exams
There are other difference as well:
Good outcomes for planned out-of-hospital birth have been demonstrated in several countries. However, these settings have system characteristics that help to maximize safety. Chief among these is a robust system of consultation and referral/transfer that can assure seamless care for the woman and her newborn when transfer is needed. In addition, these systems include thorough education (informed consent) of women and families about the potential need for consultation/referral/transfer and the potential risks associated with having a delay to receipt of emergency obstetric and neonatal care.
Consideration of distance and time from a hospital able to provide emergency obstetric and neonatal services is important in managing intrapartum complications and in providing fully informed consent. Another characteristic is written agreements that cover consultation/referral/transfer and a welldefined and practiced system of transfer. Out-of-hospital birth attendants in these systems are appropriately trained and experienced in the identification and management of obstetric and neonatal emergencies, and are also licensed and certified. These providers should be capable of initiating appropriate newborn resuscitation, and be able to provide standard newborn care in addition to the routine postpartum care of women. Certification requirements for the practice of midwifery can vary significantly between the U.S. and other countries, with U.S. requirements for midwives, other than CNM/CMs, generally being less rigorous with regard to both years of formal education and experience.
These new restrictions are just the first shot across the bow. Even NARM and MANA can see the handwriting on the wall: the CPM certification is going to be phased out. As a result, they have created the Midwifery Bridge Certificate.
NARM is planning for the day when the CPM certification will no longer be enough:
Opposition to the licensure of CPMs has centered on the lack of a requirement for an accredited education. Work among the seven US MERA organizations in 2015 created a joint statement of support for licensure legislation on the condition that it include a requirement for a graduation from a MEAC accredited program or the Midwifery Bridge Certificate.
Both the HERC regulations and the NARM Bridge Certificate represent an extraordinary victory for homebirth safety and a tremendous vindication for those who have been arguing for years that American homebirth midwifery is both substandard and unsafe.
We have been heard!
