MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

Tag Archives: Board of Direct Entry Midwifery

Leg Update for MotherBaby Bills in Oregon

Two of three motherbaby-oriented bills signed into law so far…

Midwifery Bill

HB 2380 passed the House Ways and Means Committee yesterday and now goes to the Senate floor. This bill creates a majority of licensed direct-entry midwives on the Oregon Board of Direct Entry Midwives, establishes protected peer review for licensed midwives, alters birth statistic collections to accurately record midwife-attended births (including transports), exempts receiving physicians from liability for injuries caused by a transporting midwife and distinguish outcomes between licensed direct-entry midwives and direct-entry midwives who are not licensed. 2380 goes a long way toward improving maternal health and birth outcomes through the provision of accurate statistics.

According to the Oregon Midwifery Council (a bill supporter), the Oregon Medical Association and Oregon Health & Sciences University support 2380.

The current legislative session is drawing to a close. Bill supporters are encouraged to contact their representatives  in the Senate to encourage a “yes” vote.

Increased Awareness for Maternal Mental Health Illness

On June 2nd, Governor Kitzhaber signed HB 2235 into law, creating the Maternal Mental Health Patient and Provider Education Program within the Oregon Health Authority. This program will produce and provide health-care providers with materials and training about maternal mental health illness during pregnancy and within one year following birth. Rep. Carolyn Tomei (D-Milwaukie) sponsored the bill. Among key supporters and advocates for HB 2235 was Lane County’s Eugene-based WellMama, Inc.’s executive director Amy-Rose White.

24 percent of Oregon’s new mothers self-report depression during and/or after pregnancy. Maternal mental health illness can include depression, anxiety, inability and disinterest in sleeping and eating, and overpowering feelings of failure, despair and inadequacy. While effective screening and treatment exist, the vast majority of affected women are never diagnosed or connected with services.

HB 2235 originally included funding for a provider training program and required that providers make educational material available to pregnant women. The Lund Report reports that medical groups including the Oregon Medical Association and the Oregon Pediatric Society objected to mandatory provision of information. Funding was also stripped and provision of educational materials is now optional. Maternal health advocates envision future legislation to make maternal mental health screening part of the standard of care for pregnant women.

Read coverage in The Statesman Journal and The Lund Report.

Impact of Doulas in Improving Maternal Health

Earlier this month, HB 3311 was signed into law. Under the new law, the Oregon Health Authority will investigate how doulas (birth companions) improve birth outcomes for women at disproportionate risk for poor birth outcomes. Rep. Tina Kotek (D-N and NE Portland) and Rep. Lew Frederick (D-NE Portland) sponsored the bill. Portland-based International Center for Traditional Childbearing played a critical role in the introduction of the bill.

Doulas are labor companions who provide emotional, non-medical support associated with positive outcomes and all-too-frequently absent from a laboring woman’s side. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period.

According to The Lund Report, Oregon’s infant mortality rate among African Americans is 9.4 per thousand, compared with 5.5 per thousand in the Caucasian population. The Urban League of Portland reports African-American babies are roughly twice as likely as white babies to be born with a low birth weight. Lane County’s  disturbingly high rate of fetal-infant mortality highlights the need to focus on disparities and gaps in care.

Read coverage in The Lund Report.

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OR state leg update – 2 bills of special interest to moms and babies

Following is an update on proposed 2011 Oregon state legislation with the potential to influence perinatal outcomes.

Oregon House Bill 2380

Recently amended, HB 2380 creates a majority of licensed direct-entry midwives on the Oregon Board of Direct Entry Midwives. This is accomplished by reducing the total number of board members from eight to seven. The bill also establishes protected peer review for licensed direct entry midwives. Additionally, the bill requires the Board to collect and report birth data. Outcomes between licensed and unlicensed direct entry midwives will be distinguished in Board reporting.

Before amendment, HB 2380 would have required Oregon’s direct-entry midwives to become state licensed providers. This would have replaced the current voluntary licensure system. MotherBaby Network blogged about this proposed requirement shortly after the bill was  introduced in February. The Lund Report just reported on amending of this bill.

The Oregon Midwifery Council supports HB 2380 and encourages its supporters to contact their state representative in the House to encourage a “yes” vote.

Oregon House Bill 3311

HB 3311 has been amended to require that the “Oregon Health Authority, including the Office of Multicultural Health and Services, shall explore options for providing or utilizing doulas and other community health workers in the state medical assistance program to improve birth outcomes for women who face a disproportionately greater risk of poor birth outcomes.” If passed, OHA would report outcomes to the Health Care Committee in February 2012.

The original bill language focused on improving outcomes for women of color. The amended language is improved by expanding 3311’s focus to include all women who are at a disproportionate risk for poor outcomes. This bill is of particular interest for Lane County, where MotherBaby Network originates, given its disturbingly high rate of fetal-infant mortality. Our overall rate is higher than the nation; higher than the state; and higher than comparable counties and metropolitan areas.

HB 3311 has the potential to address gaps in maternity services by better-integrating doulas and community health workers into the model of care. Doulas are labor companions who provide the emotional and non-medical support all to frequently absent from a laboring woman’s side. Doulas are a well documented evidence based and non-medical intervention with a proven track record for positively influencing the social, physical and emotional outcomes of the perinatal period.

HB 3311 follows Amnesty International’s 2010 release of Deadly Delivery: The Maternal Health Care Crisis in the USA.  Amnesty International reports that despite spending more than any other country on earth on maternal health, US women are at greater risk of dying of pregnancy-related complications than their counterparts in 49 other countries including Kuwait and Bulgaria. Among US women, African-American women are nearly four times as likely to die of pregnancy complications than white American women.

HB 3311 enjoys support from bill sponsor Rep. Tina Kotek as well as from the following organizations:

Coalition of Local Health Officials

International Center for Traditional Childbearing

The Urban League of Portland

Mandatory Licensure for Midwives?

Oregon State Represenative Mitch Greenlick has introduced House Bill 2380 to the Health Care Committee. 2380 requires all direct-entry midwives in the state to become licensed providers. If passed, this bill would replace Oregon’s voluntary licensure program for direct-entry midwifery. Bill 2380 contains an emergency clause making it effective upon signature by the Governor meaning it is not subject to referendum.

Bill 2380 would limit the freedom pregnant women in Oregon currently enjoy in selecting a provider. The options include OB/GYNs, Certified-Nurse Midwives, Licensed-Direct Entry Midwives and Direct Entry Midwives. Depending on the choice of provider, women birth at home, in birth centers and in hospitals. Under 2380, Oregonians would lose the legal right to be attended by a direct-entry midwife. These midwives practice independently of constraints imposed by the Oregon Health Licensing Agency.

Need help sorting out Midwifery Credentials and Terms? Read this Guide.

Among direct-entry midwives in Oregon, some 60 are voluntarily licensed by OHLA. Licensed direct-entry midwives practice within the scope defined by administrative rules that the Board of Direct Entry Midwifery develops. New licensure rules were recently adopted. Licensure entitles LDMs to carry legend drugs and devices and to bill insurers for reimbursement. OHP, PEBB and some private insurers reimburse.

Direct-entry midwives forego licensure for many reasons. Foremost is preserving independence in practice. Because they are not constrained by licensure, they may serve women that LDMs cannot. Women select independent midwives for many reasons including the desire to give birth in an environment free of state regulation.

A consumer-led effort is surfacing in the form of Oregon Birth Rites. This website encourages Oregonians to contact Rep. Greenlick and their own representatives to discourage moving this bill any further.

Greenlick also introduces bill forbidding bike transport for kids under six

Representative Greenlick also introduced House Bill 2228. This bill seeks to prohibit the carrying of children six years or younger on the back of a bike or in a trailer. The bill is causing an outcry.

According to BikePortland.org blogger Jonathon Maus, Rep. Greenlick introduced the legislation before identifying a strong body of supporting evidence. Maus characterizes Greenlick’s approach as proposing legislation to stimulate public debate. In the comments field for Maus’ post, Representative Ben Cannon weighs in:

“I take Mitch at his word that he introduced the bill in order to “start a conversation” about bicycle safety. It might seem strange, but this is the way the process often works: a legislator gets an idea, drafts a bill, introduces it, gets feedback, and then decides whether to try to proceed, perhaps with amendments, or whether to let it die. Remember that a bill has to pass at least two committees, plus the House and the Senate, and be signed by the Governor, in order to become law. This proposal is a long way from that. “

If the premature introduction of a bill is the best way for Oregon’s legislators to generate information about an idea’s potential to increase the public good, MotherBaby Network proposes and supports addressing this gap in non-partisan legislative analysis in the coming session.

Better Legislative Leadership Needed

In the spirit of protecting the public, MotherBaby Network looks forward to the day when a state legislator will advance legislation with an emergency clause to recognize and address issues that affect the large majority of childbearing Oregonians. Issues ripe for leadership include the lack of transparency in hospital and provider rates for induction, far-too-high rates of cesarean section as well as the paucity of facility-level information regarding the practice of evidence-based infant feeding. (The Surgeon General recently issued a Call to Action to address barriers to breastfeeding.) There is an abundance of easily accessible and relevant research to support legislative leadership on these issues.

Much needs to be done to reduce non-medically indicated inductions, cesarean section and infant supplementation. These issues are just waiting for an elected leader with the courage and fortitude to work through the barriers separating women and families from excellent motherbaby outcomes before, during and after birth. Oregon’s elected leaders would serve the greater good by building on our current system of respect for individual freedom. We need legislation that increases transparency within the healthcare system that most women are actually using. This kind of governance would dramatically address an absence of necessary information and empower consumers of maternity care to make informed decisions.

Let’s take the plunge and go where the biggest, toughest problems reside — the hospital-based system. Let’s make that better. The overwhelming majority of Oregonians receive their care in hospitals. Encouraging more transparency within this model of care would have broad and deep positive impact on the lives of Oregonians.

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Latest on Midwifery Board rules / Shout Out to Midwifery Supporters

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)
  • Breech
  • Twin.

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:

  1. Are the flaws fundamental enough to preclude one’s overall support?
  2. 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
samie.patnode@state.or.us
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 info@oregonmidwiferycouncil.org.

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.

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New rules for the Oregon Midwifery Board?

Last month, the Oregon Board of Direct Entry Midwifery (Midwifery Board) voted seven to one to submit revised administrative rules to the Oregon Health Licensing Agency (OHLA).

This is the latest development in a nearly ten-month process of literature review, expert testimony and public comment. Not altered since 1993, the administrative rules regulate licensed direct entry midwifery. They include definitions for certain births that may not be attended by the state’s 65 licensed direct-entry midwives (LDM). Click here for a definition of LDM.

Proposed rules: http://www.oregon.gov/OHLA/DEM/Midwifery_Laws_Rules.shtml.

What should consumers know?

The draft rules are evidence based and serve the vast majority of practicing LDMs and Oregon women desiring their care. They identify three new types of high or absolute-risk birth that may not be attended by a LDM:

  1. Three cesarean sections unless previous successful vaginal birth
  2. Monochorionic, monoamniotic twins
  3. Breech where feet or knees are presenting and fetal hips are extended (Proposed Div 25 & 30 – p. 7)

Additionally, there is a new non-absolute risk requiring consultation with another Oregon licensed health care provider, including an LDM, with appropriate experience. Here is the new non-absolute risk:

Lack of adequate progress in vertex presentation is when there is no progress after a maximum of three hours in cases with full dilation, ruptured membranes, strong contractions and sufficient maternal effort; (Proposed Div 25 & 30 – p. 14)

Following is the definition of consultation:

For the purpose of this rule “Consultation” means a dialogue for the purpose of obtaining information or advice from an Oregon licensed health care provider who has direct experience handling complications of the risk(s) present, as well as the ability to confirm the non-absolute risk, which may include but is not limited to confirmation of a diagnosis and recommendation regarding management of a medical, obstetric, or fetal problems and condition. (Proposed Div 25 & 30 – p. 16)

Time to wrap it up

The revision process has been a long, fraught one. There are individuals and organizations that no doubt view the draft rules as granting too much or too little scope of practice for LDMs. It is critical for consumers in support of the Midwifery Board’s more than ten-month effort to balance these views by publicly supporting its recommended rules.

Consumer voices make a significant difference. Letters and public testimony make an impression on elected officials and appointees. Earlier in the revision phase, letters and public testimony demanding continued access to LDMs most certainly strengthened the position of like-minded members on the Midwifery Board. As a result of public accountability, these members were better able to counter efforts to impose unwarranted restrictions on individual choice in maternity care and to instead press for governing rules that are in step with consumer preference and evidence-base care.

Consumer power works

Earlier this year, state employees and dependents petitioned the Public Employees Benefit Board to restore access to maternity care with LDMs after it erroneously denied claims and gave incorrect benefit information to individuals desiring this benefit. And, just last month, PEBB stated it would defer to the Midwifery Board when determining coverage for LDM-attended births.

More than 140,000 Oregonian are covered by PEBB. This makes the recent decisions a significant and positive development for choice in maternity care.

Grab your pen

Write a letter of support to the Oregon Board of Direct Entry Midwifery and send it to:

Samie Patnode, Policy Analyst
700 Summer St NE, Suite 320
Salem, OR 97301-1287
samie.patnode@state.or.us
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 info@oregonmidwiferycouncil.org.

Come to Salem

On October 28, 2010, the agency and the board will hold a public hearing where a contracted hearings officer will receive oral testimony. More info here.

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