WISCONSIN SECTION - AMERICAN COLLEGE OF
OBSTETRICIANS AND GYNECOLOGISTS

Position statement on 2005 Assembly Bill 709 and 2005 Senate Bill 477

The Wisconsin Section of ACOG has reviewed both proposed bills.
These bills propose licensure of a new category of health care provider that is not a licensed nurse midwife. Both bills permit licensure to applicants who hold a certificate from the North American Registry of Midwives or the American College of Nurse Midwives with the specific purpose of licensure to supervise and practice home births.
Neither bill requires:

1) a minimal standard of education, passage of a standardized national
exam or recertification that provides adequate knowledge of
complications of childbirth

2) pharmacology education while allowing administration of
medication

3) malpractice insurance coverage as is required for physicians and
certified nurse midwifes in Wisconsin

4) statewide practice guidelines (agreed upon by obstetricians, family
physicians and trained midwives) for consultation, transfer and
referral so patients are safely triaged to the appropriate location for
birth prenatally and during labor and most importantly,

5) a collaborative practice agreement with physicians or certified
nurse midwives who can assume care in a hospital setting in case
complications require transfer.

Without these requirements home birth cannot be considered a safe
option. While these requirements may improve safety significantly, the
American College of Obstetrician and Gynecologists (ACOG) currently
opposes out of hospital birth.

We recognize that there are cultural, religious and personal reasons why
women and communities in Wisconsin prefer home birth.

We recognize that some women have concerns that the hospital setting for childbirth leads to more interventions. However, we cannot ignore the fact that childbirth in Wisconsin has become safer for mothers and babies over the last 6 decades due to improvements in medical technology
and improved access to trained providers and emergency obstetrical and neonatal care.

Without doubt the move from home birth to hospital birth contributed to the reduced chance of death due to childbirth for women and the improved survival rates for children.

Should women choose to assume the risk of homebirth, it should be attended by appropriately trained health care providers in a transparent continuum of care under practice guidelines that attempt to make birth as safe as possible in that setting for the best possible outcome for mothers
and children.

The literature suggests that under the above circumstances the risks of home birth may be reduced as long as:
1) there are enforced criteria to determine who is a low risk candidate for home birth and who needs consultation or transfer prior to birth or during the birthing process

2) there are agreed upon practice guidelines for all health care providers necessary to achieve safe motherhood

3) there are collaborative practice agreements guaranteeing smooth transition of care in the event of emergency and

4) distance and transportation from home to hospital are not impediments to timely care.

This type of arrangement describes the current required practice relationship between physicians and licensed certified nurse-midwives in the state of Wisconsin.

In our review of the criteria for training and credentialing by the North American Registry of Midwives, we observe that their training requirements fall short of internationally established standards for the term “midwife” versus “traditional birth attendant”. They have not adopted a
set of criteria for patients who may be appropriate candidates for home birth. Instead, they adhere to a principle where the midwife and the patient determine individual practice guidelines for an individual patient on the standards, values and ethics held by the midwife and the patient,
not on public safety criteria or generally accepted medical evidence. The midwife philosophy states, “we support each midwife to study and grow in experience until SHE knows she is a competent attendant, realizing that no amount of certification can create for someone the intuitive certain readiness for the responsibility of a midwife.”

This philosophy should be of concern from a public licensure and safety perspective. To what extent should we protect the public from unsafe medical practice or unsafe perceived medical practice? We may want to respect the maternal autonomy and cultural and religious beliefs that make women choose to have an out of hospital birth with traditional untrained birth attendants or, by most standards, inadequately trained lay midwives. Does that mean we have to create public support and licensure for homebirth practice by inadequately regulated, inadequately trained self-anointed midwives?

Does not licensure of midwives mean and require that the public can be assured that the licensed individuals are competent in recognizing high and low risk pregnancies, and are knowledgeable about complications of childbirth? Does licensing not require that they are knowledgeable about preventable conditions in pregnancy and screening required by state statutes?

The public should expect that a health care provider is competent, practices safely and with a defined standard of care. These bills provide licensure for an inadequately trained individual to provide medical care and should not be passed.Physicians or nurse midwives who support or back up care of the proposed new category of professional midwives or currently support or back up lay midwives, in our opinion, violate professional ethical standards by condoning/supporting substandard practice without practice guidelines.

When asked to provide consultation, the consultant should do so in a timely manner and without regard to the specialty designation or qualifications of the referring practitioner. If the consultant believes that the referring practitioner is not qualified to provide an appropriate level of continuing care, the consultant should recommend to the referring practitioner and, if necessary to the patient that the referring practitioner transfer care of the patient.

To protect these physicians from ‘vicarious liability” as both of these bills do equals “protecting physicians from liability for substandard care/advice.” It is unacceptable to provide liability protection to midwives and physicians under both of these bills for substandard medical practice. Both of these bills create less safety for childbirth in Wisconsin. Both of these bills devalue the meaning of a “trained midwife”. We oppose the adoption of these bills and the licensure of a separate category of midwife.

We support the practice and licensure of appropriately trained midwives as those credentialed by the American College of Nurse Midwives. We support collaborative practice agreements between physicians and certified nurse midwives and practice guidelines with the requirement of malpractice insurance coverage.

The Wisconsin ACOG Section strongly urges the Legislature and Board of Medical Examiners to examine unsafe birthing practices in this state and take immediate aggressive action to ensure the health and welfare of women and babies in Wisconsin.