Latest development in OARS
The Oregon Board of Direct Entry Midwifery is near the end of a yearlong process of revising the Oregon Administrative Rules (draft rules) that govern licensed direct-entry midwives (LDMs). With a few exceptions, LDMs are the sole providers of home birth services in Oregon. In September, draft rules developed by the “Rules Advisory Committee” received seven-to-one support from the Midwifery Board. (Read earlier post and reference the Guide to Midwifery Credentials and Terms in Oregon)
Following a subsequent month of written public comments and an October 28 public hearing, the Oregon Health Licensing Agency (OHLA) —oversight agency for the Midwifery Board— extended the written public comment period by 30 days. OHLA cites the “high volume of public comment and diverse nature of topics” for the extension.
Consumers underrepresented at public hearing
Advocates for choice in maternity care have expressed concern over so few consumers and supporters of LDM care attending the hearing. Consumer Minna Pavulans offered the only such perspective. (Read a consensus letter Pavulans helped draft earlier this year.) The small showing contrasts with a large Spring 2010 convergence in Salem of the many women, partners and babies registering demands for continued access to LDMs.
In contrast, LDM opponents were in high attendance at the recent public hearing, achieving the strategic benefit of over-representation for their views. Requests included altering the draft rules to forbid LDMs from serving women with the following kinds of pregnancies:
- Vaginal birth after cesarean (VBAC)
The proposed draft rules permit LDMs to serve women with most of these kinds of pregnancies. This is a major victory for maternity choice advocates and likely an choice in care unique to Oregon. LDM opponents also asked that practicing LDMs be required to secure $1 million liability insurance. Obtaining this level of coverage is almost certainly impossible.
Within the licensed direct-entry midwifery community, a lack of basic accord on the draft rules exists. Discerning if the LDM community generally views the rules as mostly okay with a few exceptions or mostly unacceptable is difficult. In contrast to LDM opponents, it is proving hard for this constituency to convey a consistent, strong message to the Midwifery Board.
Ironically, as midwives debate the impact of the draft rules on choice in maternity care, the position of individuals and groups pushing for additional restrictions improves. For good or bad, boards respond most to constituencies with clear and consistently conveyed demands.
What does freedom of choice mean in the context of licensure?
In Oregon, direct-entry midwives may practice with or without a license. Women select licensed or unlicensed direct-entry midwives for numerous reasons. Three common reasons for selecting a licensed midwife include:
- Insurance reimbursement. Some health insurance plans, including that of the Oregon Public Employee Benefit Board and Oregon Health Plan, reimburse for LDM care.
- Professional standards. To gain licensure, midwives demonstrate evidence of core competencies and pass written exams.
- Legend Drugs and Devices. LDMs legally carry and administer anti-hemorrhagics, medical oxygen, IV fluids, anaphylactic treatment and local anesthetics among other items.
In selecting a LDM, a woman opts into a model of care in which state-endorsed rules govern the terms of licensure. Rules for who midwives may serve, when additional consultations are required and consumer recourse in the event of a complaint are just a few of the many areas in which the midwife-client relationship is shaped by codified guidelines.
However a woman defines the benefits of licensed direct-entry midwifery, they are gained in the context of the rules of licensure. Rules, by their very nature, infer limits. The Midwifery Board’s most pressing task right now is to determine what those limits on scope of practice should be and how to articulate them in the new set of rules.
Support for imperfection?
Are the draft rules perfect? Must they be to garner general consumer support? The answer is “no” on both accounts.
By virtue of having been drafted by a group of individuals —each with a unique set of convictions, beliefs and biases— the rules are necessarily imperfect. This is not the same as saying they are unworthy of support. Another litmus test is to assess to what extent the divergent views have been transparently negotiated with evidence-based findings setting the standard for debate.
Consumers can also assess their personal level of support or opposition for the draft rules by asking two questions:
- Are the flaws fundamental enough to preclude one’s overall support?
- Is a better outcome possible given current political realities?
Consumers, make your thoughts known
Having dominated the public hearing, LDM opponents have everything to gain by redoubling their efforts. Despite a poor showing at the public hearing, it’s not too late for consumer feedback to stabilize what is turning out to be an unpredictable conclusion to a yearlong revision. Consumer participation earlier in the process is credited for strengthening the position of advocates for choice in maternity care. To the degree that the rules protect those choices, consumers deserve credit. To get the job done, more letters (yes, another letter!) are needed to empower the Midwifery Board to resist yielding to extreme positions.
Supporters (and opponents) of the LDM model of care have through Sunday, November 28 at 5pm to weigh in. Email or mail your letter here:
Samie Patnode, Policy Analyst
Oregon Health Licensing Agency
700 Summer St NE, Suite 320
Salem, OR 97301-1287
Work: (503) 373-1917
Fax: (503) 585-9114
Send it to your elected representatives and post it on your personal Facebook pages. Send it to Oregon Midwifery Council at email@example.com.
Invite partners, family and friends who support choice in maternity care to write letters, too. Share your letter with them to help them get started. Offer to send it in for them.