MotherBaby Network

advocacy and commentary with a focus on Lane County, Oregon

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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 cesareanrates.com.

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

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Oregon Health Plan applications should be expedited for pregnant women

Low-income pregnant women in Oregon experience too many delays in completing the Oregon Health Plan application process. These delays run counter to Department of Human Services policy requiring applications by pregnant women be expedited and processed within two business days. DHS branches must have or develop a specific process for expediting applications made by pregnant women.

Inadequate prenatal care is linked to increased risk for low birth weight, prematurity and infant and maternal mortality. Lane County fetal-infant mortality data for the period of July 2007 to June 2010 shows than 34% of affected families accessed prenatal care after the first trimester.

In an effort to minimize delays stemming from policy non-compliance, DHS has sent a policy transmittal to case workers and eligibility workers who process OHP applications. The transmittal reiterates and clarifies existing policy that until now has had variable degrees of implementation. Women can verify pregnancy with an informal note from a medical clinic or crisis center. Neither a note from a doctor, nor an ultrasound are required – though an ultrasound may be used for verification purposes.

“Emergent medical needs, and those who are pregnant, have priority when processing applications for medical. They do not need to disclose the basis of their emergent need. The application should be pended, approved or denied by the eligibility worker within one business day whenever possible.” – DHS transmittal

Pregnant women can print and bring this transmittal with them when applying for OHP. Regardless of a woman’s plans for her pregnancy, she is entitled to have her application expedited. If a woman planning to terminate her pregnancy encounters delays, this should be reported to the Network for Reproductive Options (NRO).

Special thanks to Representative Mitch Greenlick for providing legislative intern Jessica Matthews, MPH, the opportunity to work on this issue. Matthews worked with the Oregon Health Authority to clarify and communicate the correct policy. Thanks, too, to Bayla Ostrach for sharing the data from her master’s thesis that found low-income pregnant women in Oregon experience notable delays in the OHP application process.

Wider awareness of this policy can help to further eliminate bureaucratic barriers to pregnant women seeking access to care – spread the word. If you have a website or blog, post the DHS transmittal.

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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Sacred Heart to become Baby Friendly, McKenzie-Willamette exploring designation

Since posting Project Aims to Improve OR Hospital-Based Breastfeeding Services, MotherBaby Network has received a good deal of positive feedback from individuals in healthcare, elected office, local government, the insurance industry, the non-profit sector as well as from consumers. The post describes a new statewide project (Oregon Hospitals Partnering for Evidence-Based Infant Nutrition) that support hospitals in developing the evidence-based infant feeding practices associated with increased rates of breastfeeding and better health outcomes.

MotherBaby Network received the following information from Sacred Heart Medical Center and McKenzie-Willamette Medical Center regarding plans for the Baby Friendly designation at each facility. Pursuit of this designation provides facilities with a clear pathway for developing the knowledge and effective practices to properly support breastfeeding. It is a clear signal to women and families that they can have confidence in a facility’s infant feeding services.

Sacred Heart Medical Center Intends to Become a Baby Friendly Facility

Sacred Heart Medical Center will pursue the Baby Friendly Hospital Initiative’s designation. An interdisciplinary group of L&D nurses, physicians of several specialties and administrators has been formed. A letter of intent to Baby Friendly will go out before July 1, 2011.

McKenzie-Willamette Medical Center Exploring Baby Friendly

McKenzie-Willamette Medical Center is exploring pursuit of the Baby Friendly status.

If both SHMC and MWMC were to become Baby Friendly, evidence-based infant-feeding would become a community standard. Hopefully, both hospitals will join the new collaborative, statewide hospital effort to support these efforts. Interested parties should contact Amelia Psmyth at Amelia@breastfeedingOR.org or Desiree Nelson at Desiree@breastfeedingOR.org.

These latest state and local developments around breastfeeding reform occur in a national context of growing awareness and support for improving the circumstances in which women, families and communities welcome babies. Issuing the first-ever Call to Action for breastfeeding reform, Surgeon General Regina M. Benjamin is the latest national figure to add her support. Describing the multiple, overlapping barriers in communities, healthcare systems and places of employment, Benjamin urges the nation to remove them so that women will no longer be forced to stop breastfeeding sooner than they want or discouraged from initiating breastfeeding. More information: www.surgeongeneral.gov.

Interested in what local women and families who have used evidence-based breastfeeding services have to say? Read Lane County Friends of the Birth Center’s consumer survey.

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Lane Co’s extends prenatal to women ineligible for OHP due to immigration status

Following six other counties, Lane County is implementing Oregon’s Prenatal Expansion Program to provide Oregon Health Plan (OHP) Plus Prenatal services to pregnant women who have “Citizen / Alien Waived Emergency Medical” (CAWEM) coverage.

Expansion of CAWEM coverage to include prenatal care is made possible through the federal Children’s Health Insurance Program (CHIP) that allows States to serve the unborn children of women who would be Medicaid-eligible except for immigration status. Oregonians access Medicaid through OHP.

The CAWEM Plus prenatal benefits are the same as OHP Plus with four exceptions: sterilizations, therapeutic abortions, hospice care services and death with dignity services. Maternity coverage ends at delivery, unless postpartum services are provided through a bundled (packaged) rate. The newborn will be enrolled in OHP Plus for one year of automatic eligibility.

Providers accepting OHP can now serve CAWEM Plus clients. For more information, see the Provider Alert Sheet (includes Spanish-language description) and Quick Facts. Clients can enroll at any Department of Human Services site.

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Project Aims to Improve OR Hospital-Based Breastfeeding Services

With funding support from Oregon WIC and Multnomah County Health Department, the Breastfeeding Coalition of Oregon (BCO) recently launched a new statewide project – Oregon Hospitals Partnering for Evidence-Based Infant Nutrition. This project supports hospitals in developing the evidence-based systems associated with increased rates of breastfeeding.  The project aims to promote evidence-based hospital maternity practices related to breastfeeding by offering technical assistance, convening a spring 2011 hospital summit, and supporting the formation of a hospital collaborative learning community.

Lane County’s Desiree Nelson joins the project’s four-member team:  BCO Director Amelia Psmythe, Helen Bellanca, MD, MPH, Rachel Burdon, RN, MPH, and Mary Lou Hennrich, RN and Executive Director of Oregon Public Health Institute (OPHI).  Oregon WIC allocated federal funds for increasing breastfeeding rates through outreach to hospitals. Locally, Nelson is well known for co-founding Baby Connection, a phenomenally successful live demonstration of Baby Friendly step 10:

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Arriving early and leaving well after closing time, families and babies consistently demonstrate the very real but unmet demand for weekly, drop-in evidence-based lactation support in the weeks and months following birth.

Key Backers

The BCO’s parent organization, the Oregon Public Health Institute recently formed an innovative working group for health insurers – the Oregon Health Insurers Partnering for Prevention (OHIPP). The first of its kind in the nation, OHIPP is a collaborative obesity prevention effort between health plans and public health policy advocates.

Currently, six health insurers participate in OHIPP – representing 65% of private insurance and 45% of Medicaid. Insurers contribute money to fund selected interventions. Because breastfeeding is increasingly associated with reduced risk of childhood obesity, OHIPP has selected increasing breastfeeding rates as its first collaborative public health intervention.

OHIPP’s direction could have a huge impact on breastfeeding practices in Oregon. Imagine, for example, the impact of a reimbursement system in which rates for births were higher for hospitals certified as evidence based by the Baby Friendly Hospital Initiative. This type of innovative intervention conveys the importance of becoming evidence based and signals growing understanding that evidence-based care is preventive and effective in the long run.  In this scenario, hospitals would be incentivized to seek support and resources like those the BCO is offering through this project.

Additional critical support for evidence-based breastfeeding services comes from the Oregon Association of Hospitals and Health Systems (OAHHS). A recent OAHHS membership survey indicates 85% of nurse managers are aware of the gold standard for evidence-based breastfeeding support systems – the Baby Friendly Hospital Initiative. 39% want technical assistance and support on Baby-Friendly 10 Steps. Plans are underway for OAHHS to partner with the BCO to co-brand educational opportunities and communicate the importance of evidence-based breastfeeding support to its membership.

Hospital Outreach

The Oregon Hospitals Partnering for Evidence-Based Infant Nutrition project is in the initial outreach phase to hospitals and health system leaders. Interested hospitals are encouraged to begin forming multi-disciplinary teams for the purpose of assessing current internal practice. Representatives from these teams will be invited to participate in a Spring 2011 summit for a day of education, group facilitation and collaboration. Participants will be encouraged to form an ongoing network of communication between their facilities, to support the path toward institutional change.  Interested hospitals should contact Amelia@breastfeedingOR.org or Desiree@breastfeedingOR.org for more information.

Lane County’s PeaceHealth Nurse Midwifery Birth Center is one of four Baby Friendly Hosptial Initiative-designated facilities in Oregon. Community and consumer support for moving the birth center from downtown Eugene to the new Sacred Heart Medical Center campus in Springfield were centrally linked to the unwavering demand for ongoing access to evidence-based breastfeeding services. Judging by the outcomes and immense demand for these services, making them available at the county’s two leading hospitals, Sacred Heart Medical Center (SHMC) and McKenzie-Willamette Medical Center would be a tremendous boon for families and communities.

Next week, Lane County Friends of the Birth Center will release results from a recent survey taken by more than 100 local women and families describing their experiences evidence-based breastfeeding services at the PeaceHealth Nurse Midwifery Birth Center. Demonstrating the connection between evidence-based services and consumer satisfaction, LaneCoFBC intends the survey to encourage all Lane County hospitals to achieve the Baby Friendly designation. For a copy of the survey, email lanecofbc@gmail.com. (Click here to access the survey.)

Progress already

Locally, there is positive discussion of SHMC RiverBend Labor and Delivery staff’s recent innovative and successful introduction of uninterrupted skin-to-skin contact immediately following birth. Providing skin-to-skin as standard care is a very positive development because it is bedrock practice for developing evidence-based breastfeeding services. Babies placed skin-to-skin with their mother are more likely to be breastfed and to breastfeed for longer.

Having SHMC Labor and Delivery staff describe how front-line practices and internal systems have been altered to bring more evidence-based care to the floor is an example of useful information that could be shared at the upcoming Spring 2011 summit hosted by the Oregon Hospitals Partnering for Evidence-Based Infant Nutrition project. Attending health professionals would return to their respective hospitals with a concrete, doable action for improving mother-baby breastfeeding outcomes.

Writing on the wall

Discussion of evidence-based breastfeeding care is a roundabout way of saying hospitals should identify ways to understand and implement Baby-Friendly practices. Savvy hospitals understand consumers, legislators, government agencies, the business community and accreditation bodies have connected hospital-based breastfeeding practices with the success mothers and babies have in the months following discharge.

Perusal of the following links demonstrates a trend toward adoption of Baby Friendly language for discussions of evidence-based care. They also demonstrate large-scale convergence around breastfeeding as a top-ranking major objective in health care.

  • The Joint Commission’s new perinatal care core measure set includes exclusive breast milk feeding

The question hospitals must answer about breastfeeding services is no long whether or not to become evidence based but (1) how to do it and (2) how to demonstrate that it is being done. Because Baby-Friendly is the established and universal standard for effective breastfeeding care, pursuing and maintaining this designation answers both questions in the most expedient manner. The project’s greatest potential value to hospitals lies in the efficiencies it can generate through developing models of collaboration for identifying and removing barriers to reform. The potential for idea sharing and cost sharing for staff training and education increases significantly with each hospital’s commitment to participate.

To learn more, contact Amelia@breastfeedingOR.org or Desiree@breastfeedingOR.org for more information.

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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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