MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

Tag Archives: homebirth

Cesarean Awareness Month – April 2012

For the first time in 14 years, the 2010 US C-section rate of 32.8% is down slightly from the 2009 rate of 32.9%. This is excellent news but it is too early to celebrate. A quick look at the US Cesarean Rates from 1970 to 2010 depicts the long history of a negative trend. It will take some time to bend it positively.

How does Oregon compare with other states?

For years, cesarean section rates in Oregon hospitals and counties have far exceeded the 15% limit recommended by the World Health Organization. Oregon Public Health Authority (OPHA) data for 2011 indicates a state rate of 28.94% – down slightly from 29.45% in 2010. Unfortunately, Lane County’s Sacred Heart Medical Center RiverBend (35.18%) and McKenzie-Willamette Medical Center (29.71%) are above the state average and well beyond recommended rates.

The State of Oregon proclaims April Cesarean Awareness Month.

State of Oregon Proclamation: April is Cesarean Awareness Month

OPHA collects birth certificate statistics for vaginal, VBAC and cesarean section deliveries by county, facility and out of hospital settings. Cesarean sections resulting from birth center, home birth or inter-hospital transfer are not disaggregated. Using 2011 data, the following tables were created by MotherBaby Network. Download the OPHA document

Tables for Oregon 2011 using OPHA Data (download tables)

  1. Hospital Rates for –C-Section and VBAC
  2. C-Sec and VBAC Rates for Hospitals with more than 1000 births
  3. County C-Sec Rates
  4. County Out-of-Hospitals Births (Birth Center and Planned Home Births)
  5. Lane County Vaginal, VBAC and C-Sec Rates by Facility

Cesarean section can be a lifesaving technique for both mother and infant. When practiced in the absence of medical benefits, however, the risks outweigh the benefits of vaginal birth. Potential risks to babies include: low birth weight, prematurity, respiratory problems, and lacerations. Potential risks to women include: hemorrhage, infection, hysterectomy, surgical mistakes, re-hospitalization, placental abnormalities in future pregnancies, unexplained stillbirth in future pregnancies and increased maternal mortality.

The California Maternal Quality Care Collaborative (CMQCC) recently published a comprehensive White Paper on the state’s cesarean section rates. In addition to confirming higher costs and more complications for mothers and babies, the paper reports growing evidence of greater psychological distress and illness including postpartum anxiety, depression, and post-traumatic stress disorder associated with cesarean birth as compared to vaginal.

…the widespread over-use of maternity procedures including Cesarean sections and scheduled inductions, which credible evidence tells us are beneficial only in limited situations, has resulted in longer maternity hospital stays and multiple costly procedures…sadly, despite our exorbitant expenditures on maternity care, childbirth continues to carry significant risks for mothers and babies, especially in communities of color.
– Congresswoman Lucille Roybal-Allard

To stop exposing women and babies to cesarean risk in the absence of real medical benefit, the multiple perverse incentives driving its misuse must be addressed. Provider convenience and changes in obstetric practice, misguided insurance policies, defensive medicine and financial incentives are a few needing correction. Debunking the myths of maternal request for cesarean section is also important.

Although there are undoubtedly some women who do seek elective Caesareans, they are hardly enough to increase the number of Caesareans by 400,000 nationally since 1996.
Declercq & Norsigian

As cesarean section rates increased by sixty percent over the past 15 years, access to VBAC (vaginal birth after cesarean) has diminished. In 2008, less than 13% of Oregon births after cesarean were vaginal. Most women have no choice but to have a repeat cesarean. Despite the lack of choice, this is called “elective” surgery.

Wondering if your hospital allows or bans VBAC? Find out at

Barring women from VBAC drives today’s cesarean section epidemic by fulfilling the prophecy “once a cesarean, always a cesarean.” Interestingly, this saying was originally uttered as a precaution against over use. A cursory look at Childbirth Connection’s graph of 1989 -2010 federal data for primary, elective and VBAC births shows the down-ward trend of VBAC reflecting its absence as a choice in the reproductive lives of women. Seeking to correct this barrier, the National Institutes of Health and the American Congress of Obstetricians and Gynecologists have both recently taken positions supporting VBAC as a safe option for most women.

 “… needless cesarean sections are actually harming women and babies alike. California Watch found that hemorrhaging from C-sections “is one of several possible factors in the state’s increased maternal death rate,” with the main risk coming in women who have multiple c-sections.”
The Atlantic Monthly

Since MotherBaby Network’s 2010 cesarean awareness post, four developments are positively influencing cesarean reduction in Oregon:

  • Oregon Health Sciences University Center for Women’s Health is reducing c-section by changing provider practice. How? Weekly provider reviews to discuss decisions leading to c-section and consistent counseling for women following cesarean surgery about VBAC in the future. Reviewing practices leading to cesarean section encourages a more measured, patient approach that slows the tendency to abandon vaginal birth for non-medical reasons. OHSU Center for Women’s Health director Dr. Aaron Caughey is to be commended for correctly describing the  majority of circumstances resulting in repeat cesarean section as coercive due to the fact women lack access to VBAC.

“The C-section rate in your first pregnancy matters a ton,” Caughey said. “The C-section rate is only about five percent of women with a previous (vaginal) delivery.” – The Lund Report

  • The March of Dimes’s “Eliminating Elective Deliveries Prior to 39 Weeks Gestation: OR Challenge” spurred 17 Portland- metro hospitals to implement policies eliminating non‐medically indicated deliveries before 39 weeks. This policy results in fewer failed inductions, meaning fewer cesarean sections. The Atlantic Monthly covered this important shift in community norms in Why Hospitals in Portland Are Banning Early Births. 34 of 53 Oregon hospitals have since joined the challenge to stop elective deliveries before 39 weeks.
  • The Oregon Public Health Authority collects “mode of delivery” statistics from birth certificates at facility and county levels. Beginning with 2011 data, OPHA now reports VBACs as a mode of delivery. This is key as it provides information about which facilities actually support VBAC and the number occurring on an annual basis. We should see these numbers increasing every year as hospitals and physicians return to patient-centered evidenced-based care.
  • Oregon state health care reform has the potential to transform the current model of care into one in which patient / consumer experience and community health outcomes replace billable procedures as the metric by which hospitals determine best practices.

CostCo is raising cesarean awareness and encouraging prevention in CostCo Connection magazine.

Despite these positive developments, the deck is still stacked for women seeking to maximize individual and infant health and well-being. Gaining insight into the opaque world of provider and hospital philosophies, practices and outcomes is nearly impossible. Even when women ask the right questions, the answers they receive are often unfounded, fuzzy and vague. Consequently, most  remain unaware of the real risks of being subjected to unnecessary primary- and repeat-cesarean section.

Learn more about cesarean section

Learn more about VBAC


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.


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 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.


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
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

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.


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:

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
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

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.


Access to Licensed Direct Entry Midwives

Two important events affecting ongoing access to Oregon’s licensed direct-entry midwives happened in September.

#1: PEBB defers to Midwifery Licensing Board on coverage

The Public Employee Benefit Board will continue to follow guidelines established by the Board of Direct Entry Midwifery when determining coverage for members accessing maternity care with licensed direct-entry midwives. The Lund Report’s coverage:

Midwives Retain Status Quo with PEBB

PEBB Looks into High Risk Births

#2: Midwifery Licensing Board completes review of administrative rules:

The Board of Direct Entry Midwifery has completed it’s initial review of the administrative rules. On September 13, 2010 the board recommended proposed administrative rules to the Oregon Health Licensing Agency (OHLA).  The agency filed proposed administrative rules with the Secretary of States Office which will be published in the Oregon Bulletin on October 1, 2010.

Public comment will close as of October 28, 2010, giving interested parties 28 days to comment.  On October 28, 2010, the agency and the board will hold a public hearing where oral testimony will be received by a contracted hearings officer.

Please send all comments to the following:
Samie Patnode, Policy Analyst
700 Summer St NE, Suite 320
Salem, OR 97301-1287
Work: (503) 373-1917
Fax: (503) 585-9114

The Legislation and Rules Committee will meet on December 4, 2010, to review proposed administrative rules and make final recommendations to the board of December 10, 2010.  On December 10, 2010, the full board will meet to review and consider all comments and recommendations from the committee, public and hearing officer.  At this meeting the board will recommend permanent rule adoption to the agency.

Proposed rules have been filed by Division.  Division 25 and 30 have been combined to administrative purposes.  The following are Secretary of State required documents and proposed rule text. 

PEBB restores coverage for out-of-hospital maternity care

At its April 20 meeting, the Oregon PEBB Board voted unaninmously to reinstate statewide coverage for home-based and birth center-based maternity care provided by licensed direct-entry midwives (LDM). LDM maternity services will again be covered at 70%. PEBB’s action restores this benefit as it existed since the 1990s under Regence BlueCross BlueShield.

PEBB board members cited the extensive research supporting out-of-hospital care (annotated bibliography) and PEBB Members for Maternity Care Choice’s efforts as key factors in the decision. (PEBB agenda and attachments)

During the discussion, Rep. Tina Kotek, PEBB advisory member, recommended tracking provider rates for cesarean section and induction. Cesarean section rates, often fueled by failed inductions, are increasingly and correctly understood to be overused procedures unnecessarily exposing women and babies to short- and long-term health risks. The New York Times recently reported on a Staten Island hospital successfully maintaining significantly lower cesarean rates through protocols limiting scheduled induction.

Tracking breastfeeding initiation and duration rates would also significantly further PEBB’s commitment to evidence-based, cost-effective care. A recent Harvard study published in Pediatrics concludes that suboptimal US rates result in significant excess cost and preventable infant mortality. More than 900 babies and $13 billion dollars would be saved annually, if women breastfed for six months.

Responding to accusations of “guilting” mothers, the study’s author recently penned an opinion piece making the case for reforming hospital practices. Like many other experts and advocates, she recommends hospitals achieve excellence in breastfeeding care through securing the Baby Friendly designation.


Will PEBB restore access to licensed homebirth midwives?

Next Tuesday (April 20th), the Oregon Public Employees Benefits Board (PEBB) will discuss and, hopefully, restore its members’ access to licensed direct-entry midwives (LDMs). PEBB Members for Maternity Care Choice (members) will be there to continue months-long efforts to have PEBB direct Providence Health Plans to properly process claims for LDM reimbursement. The coalition’s online petition, with more than 470 signatures, enjoys broad-based, statewide support among PEBB members. Both the Oregon State University and the University of Oregon Presidents support restoring access to LDMs.

For background read my first and second posts. Click here for a guide to midwifery credentials and terms in Oregon.

Pregnant women caught up in PEBB’s procedural gaffe

In 2009, PEBB announced it would self-insure with Providence as the plan administrator. Many PEBB members planning or desiring coverage for LDMs asked for and received repeated assurances of uninterrupted access. PEBB members using LDMs are a proactive group. For more than a decade under PEBB BlueCross BlueShield, members enjoyed access to LDM-attended homebirth. In most of the state, LDMs are the only maternity care providers offering homebirth services. Because insurance coverage for this option is not the norm, members favoring this choice were motivated to double- and triple-check PEBB’s assurances of “no change” as it announced plans to self-insure. PEBB Q&A sessions, email exchanges and close readings of the draft 2010 handbook in September indicated LDMs would, indeed, continue to be covered as an out-of-network option at 70% reimbursement.

During the fall 2009 open enrollment, many members planning for or around current pregnancies made decisions regarding flexible savings accounts predicated on LDM access. By the end of 2009, as some members prepared to submit claims to Providence, they were told this benefit choice was excluded and claims would be rejected.

Members were referred to the 2010 handbook issued in January that excludes the services of direct entry and lay midwives. This language was not included in the draft handbook. Then in January 2010, members received PEBB’s newsletter with the following “fast fact:”

  • Direct-entry midwives are not listed as providers.

Clearly, PEBB staff and Providence believe the 2010 handbook and newsletter bar coverage for LDMs. This is incorrect – neither the exclusion nor the “fast fact” pertain to licensed direct-entry midwives. LDMs fully meet current definitions of practitioner and provider in the PEBB handbook and PEBB-Providence contract. In other words, PEBB staff and Providence employees are misinterpreting these governing documents and, as a result, erroneously rejecting legitimate claims. An explanation for this about-face has yet to be provided, although as of its last meeting PEBB directed staff to provide one in writing.

PEBB documents cover LDMs

The terms “qualified practitioner” and “qualified provider” are used in the 2010 handbook and in the PEBB-Providence contract. LDMs meet the definitions in each document.

Starting with the 2010 handbook definition on page 76:

Qualified Practitioner

Qualified Practitioner means a physician, women’s health care provider, nurse practitioner, certified nurse midwife, clinical social worker, physician assistant, psychologist, dentist, podiatrist, acupuncturist, naturopath, chiropractor, audiologist, Christian Science practitioner, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license.

The Oregon Health Licensing Agency licenses LDMs. Within their scope of practice, LDMs provide prenatal, intrapartum (birth) and postpartum care. They are trained to screen for and identify risk factors falling outside their scope of practice. When necessary, they advise and help transition women into medical care.

On page 43, the PEBB handbook limits coverage for homebirth services to those provided by qualified providers. Because LDMs meet the above definition of “qualified practitioner,” they should also be viewed as a “qualified provider” of homebirth services.

Exclusions that apply to Reproductive Services:

  • All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services;
  • Condoms and other over-the-counter birth control products; and
  • Home births and all related Services, except Services provided by a Qualified Provider.

Finally, LDMs meet the definition of provider in the PEBB-Providence contract on page 37:

“Provider means a health care practitioner or facility that is validly licensed by the appropriate state agency to diagnose or treat health care conditions and is providing services within the scope of that license.”

PEBB should process claims and increase transparency

PEBB, not Providence, determines what is and what is not covered and at what level. During the transition to self-insure, PEBB and Providence employees may have been unfamiliar with the LDM choice in maternity benefit. There have been other oversights and they are being resolved. Upon learning of unintended changes in coverage for breast pumps or of a failure to recognize naturopaths as a type of primary care physician, PEBB has directed Providence to restore coverage.

Restoring coverage for LDMs is no different. It requires that PEBB see the issue for what it is – a procedural gaffe. Accordingly, it should direct Providence to correctly interpret governing documents and process LDM claims. This can be done at the April 20th meeting.

PEBB should take the additional step of increasing transparency within governing documents by specifically naming LDMs as qualified practitioners who are qualified providers.

LDM access is a win-win scenario

Ensuring proper processing of claims and tightening language will align PEBB with its governing Vision and Key Components by prioritizing transparency, cost effectiveness, evidence-based care rooted in informed choice and excellent outcomes. Subject-area expert Dr. Melissa Cheyney speaks to this:

“There’s a common misconception in the U.S. that the hospital is the safest place to give birth,” she said. “This is certainly true for higher risk women. But for low-risk women there are now 33 studies that demonstrate that with a trained care provider, when a complication arises, and the home birth is planned, that home birth is as safe as or safer than the hospital. It also results in enormous cost savings, lower rates of intervention, higher rates of psychosocial outcomes that are considered positive like prolonged breastfeeding and high satisfaction rates for the mother. So these women are actually practicing evidence-based maternity care.”

In other words, LDM-assisted homebirth is a maternity model of care predicated on health and wellbeing, the very essence of preventive care that PEBB is striving to encourage among all members.

Correcting course is also a financial win-win scenario for PEBB and its members. Women and families opting for homebirth with an LDM will generate significantly reduced claims. Roughly speaking, LDM maternity care runs approximately $3,000, meaning PEBB reimburses $2100. Hospital-based maternity care including uncomplicated birth costs approximately $16,000. In the case of planned cesarean section, insurers regularly pay more than $20,000. Coalition members project annual savings for PEBB ranging between $265,000 and $560,000.

In closing….

Regardless of the reason for selecting LDM-assisted homebirth, women who choose this option avoid the routine use of intervention and cesarean surgery to manage low-risk, normal labor. If PEBB fails to remove bureaucratic barriers, women unable to pay out of pocket will be forced into the hospital. Hospitals are struggling and mostly failing to acknowledge and correct practices fueling the nation’s cesarean epidemic and astonishingly poor track record for supporting women and babies to breastfeed. Withholding LDM-care from those who prefer it is a losing proposition for women, families and PEBB.


Coalition Petitions PEBB Board to Make Good on Word by Restoring Choice in Maternity Care

On March 16, PEBB Members for Maternity Care Choice attended the PEBB Board meeting to request reinstatement of coverage for homebirth maternity care with Oregon licensed direct-entry midwives (LDMs). Despite multiple assurances of uninterrupted access to this choice in benefit, LDMs were excluded from coverage in the 2010 Statewide Plan. The Statewide Plan is one of PEBB’s three healthcare plans; it serves nearly 80% of PEBB members. Most PEBB members learned of the exclusion through a January newsletter.

Before the meeting, the coalition issued a press release. Thirteen coalition members (photos), with newborns and toddlers in tow, attended. A petition with more than 350 signatures from OUS and state government employees was presented. Seven OUS employees made public comments in support of restoring LDM coverage to the Board. Among them were three pregnant women, a representative of the OSU President’s Commission on the Status of Women and Dr. Melissa Cheyney, an LDM and OSU anthropologist whose research focuses on out-of-hospital maternity care. Additional information is available on the coalition’s Wiki page including a letter of support from the OSU Reproductive Health Lab. PEBB archive video should also be available. The United Academics of the University of Oregon published a summary.

Based on public comments, the PEBB Board made LDM coverage an agenda item for its next meeting. In the interim, the Board directed PEBB senior administrators to draft a report explaining why and how the loss in maternity care choice occurred. The Board also requested a briefing on the research about homebirth with LDMs. Dr. Cheyney offered her expertise.


In 2009, PEBB announced plans to become more cost-effective through self-insuring. Providence Health Plans won the contract to administer the plan. By self-insuring, PEBB assumes its own risks with the goal of lowering costs. As a self-insurer, PEBB determines what is or is not covered and at what rate. This is explained in a September 2009 Q&A document:

The Board has made no changes to the current design of the healthcare plans. It is the Board, not the insurance company or administrator, that determines what is covered and at what level in the healthcare plans.

For the past ten years, PEBB members have received out-of-network coverage at a rate of 70% for homebirth with a LDM. The Oregon Board of Direct Entry Midwifery professionally licenses LDMs.

In almost all of Oregon, direct-entry midwives are the only maternity care providers offering homebirth services. Of these practitioners, those who are licensed by the state were eligible for insurance reimbursement by Regence BCBS.

Following the announcement to self-insure, many Coalition members asked for and received repeated assurances that LDMs would remain a covered choice. UO and OSU employees detail the extensive reassurances provided at Benefits Q&A sessions and via follow-up phone conversations here. In light of PEBB statements, members anticipated continued coverage under the new 2010 Statewide Plan.

After open enrollment, during which decisions regarding healthcare plans and flexible savings accounts were made, members communicating with Providence learned PEBB would reject LDM claims. No exclusion appeared in the draft 2010 PEBB Handbook. An explanation has thus far been unavailable.

After much back-and-forth, PEBB responded with a transition of care plan to continue LDM-coverage for pregnant women already in their third trimester on January 1, 2010. Last week, PEBB extended the transition period approximately six months. Coalition members appreciate the accommodation but remain committed to ongoing LDM access for themselves and others in the future.

PEBB Handbook supports coverage for LDMs

The LDM exclusion mentioned in the PEBB January newsletter and by PEBB and Providence employees is inconsistent with the 2010 PEBB Handbook.

On page 76, PEBB defines a qualified practitioner to be inclusive of LDMs:

Qualified Practitioner means a physician, women’s health care provider, nurse practitioner, certified nurse midwife, clinical social worker, physician assistant, psychologist, dentist, podiatrist, acupuncturist, naturopath, chiropractor, audiologist, Christian Science practitioner, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license.

On page 43, PEBB limits coverage for homebirth services to those provided by qualified providers. Because LDMs meet the above definition of “qualified practitioner” they should be viewed as a “qualified provider” of homebirth services.

Exclusions that apply to Reproductive Services:

  • All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services;
  • Condoms and other over-the-counter birth control products; and
  • Home births and all related Services, except Services provided by a Qualified Provider.

What should be done?

During the 2010 transition to self-insurance, it seems likely PEBB and Providence employees were unaware of and unfamiliar with the LDM choice in maternity care benefit. There have been other oversights and they are being resolved. Upon learning of unintended changes in coverage for breast pumps or of a failure to recognize naturopaths as a type of primary care physician, PEBB has direct Providence to restore coverage. Restoring coverage for LDMS is no different.

PEBB must honor its commitment not to change benefits by reinstating coverage for LDMs. Explicitly naming LDMs as a type of provider would increase transparency for everyone involved. Correcting course in this way will align PEBB more tightly with its governing Vision and Key Components prioritizing transparency, cost effectiveness and evidence-based care rooted in informed choice.

Correcting course is a win-win scenario for PEBB and its members. Women and families opting for homebirth with a LDM will generate significantly reduced claims. Roughly speaking, LDM maternity care runs approximately $3,000, meaning PEBB reimburses $2100. Hospital-based maternity care including uncomplicated birth costs approximately $16,000. In the case of planned cesarean section, insurers regularly pay more than $20,000. Coalition members project annual savings for PEBB ranging between $265,000 and $560,000.

PEBB, as a self-insured healthcare provider, should welcome lower claims as they leave resources in the reserves. Perhaps in the future, PEBB Board members will see homebirth with LDMs as a model of the excellent and cost-effective care that it looks to provide throughout the plan.

2010 PEBB changes result in lost coverage for home birth

Despite assurances of “no changes to the current design of the healthcare plans” and after a decade of insured access to home birth with licensed midwives, Oregon women covered under the new 2010 PEBB Statewide Medical Plan now and with no prior warning receive zero insurance coverage for this choice in maternity care. Before 2010, when Regence BlueCross BlueShield administered PEBB, use of a licensed midwife for home birth was covered at 70%.

The loss in coverage comes as a major disappointment to the women, families and licensed midwives in Lane County who repeatedly asked for assurances by PEBB that the new 2010 plan would continue coverage at the same rate. Had PEBB provided proper notice of the upcoming change in coverage, women, families and licensed midwives could have responded.

Instead, women desiring home birth and related services (breastfeeding support, for example) are now finding this care excluded on page 43 of the new 2010 PEBB Handbook. What does this mean? Coverage for home birth services no longer exists for PEBB employees in most (all?) of the state. Many women have long-established relations with their providers and are (were) in the midst of receiving maternity care. They now must pay out of pocket or initiate care elsewhere. Certified nurse midwives are covered but they no longer provide home birth services in Lane County or in most other communities in Oregon.

The unexpected loss coincides with the March 2010 Centers for Disease Control National Health Statistics report showing a five percent national increase in demand for out-of-hospital midwife births from 1990 to 2006. Oregon demand was greater at a growth of 6.3%.  ABC News provided coverage.

Because home birth and postpartum services are more cost effective than any other combination of provider and location, it is difficult to comprehend how lost coverage squares with PEBB’s assertion that the 2010 plan will yield better results in terms of cost. Maternity care is one of, if not the most expensive components of health insurance plans. Removing this option for women yields increases for everyone.

According to Christine Olsen, Oregon State University Research Associate in an email:

“For each mother who is forced to switch from her licensed midwife to one of the in-hospital care providers, PEBB will be paying a minimum of $10,000 more for the pregnancy and birth.  Our estimate is that this change is going to cost PEBB at least $500,000 a year (but probably much more). Noteworthy: PEBB will pay for a $20,000 elective C-section; my midwife charges $3300 for all prenatal, postpartum and birth services.”

The Board and not the plan administrator, Providence Health Plans, determines what is and what is not covered and at what level. Let’s hope the Board acts in good faith as sole decision-maker and restores PEBB employees’ choices in childbirth at its upcoming March 16 meeting. Women, midwives and supporters will attend. If you are insured by PEBB please support continued choice in childbirth, regardless of whether or not you would make the same choices, by adding your name to the following online petition: