Category Archives: Midwifery

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Why I’m feeling conflicted about AB 1306: CNM Physician Supervision vs. Home VBAC Hurdle

Update August 25, 2016 1:32pm

The Senate floor vote for this bill has been postponed until Monday.


Update August 25, 2016 9:57am

For those of you watching this issue closely, this bill will be up for a Senate floor vote today. You can watch the California Senate live here.


Update August 24, 2016 10:06pm

The Senate floor vote for AB 1306 is scheduled to happen tomorrow, August 25th. (Click here to see the current status of the bill.)

The California capital opens at 9am, so if you haven’t already called your state Senator to tell them how you feel about AB 1306, tomorrow is the time.

All you have to say is, “I’m calling to voice my support of [or opposition to] AB 1306.”

Click here to receive a reminder email tomorrow at 9am.

All my thoughts on AB 1306 can be found below.


Update August 24, 2016 11:06am 

I have thought about AB 1306 for so many hours since I initially opposed it last Friday and I’m feeling really conflicted about it.  Let me share with you why.

Removing physician supervision will improve the ability of CNMs to practice autonomously including offering VBAC in the hospital setting (where hospital policy permits) and in birth centers (provided the CNM opts to offer VBAC). This could be a good thing for VBAC families and a great thing for all the other people CNMs serve.

And so it’s really tough because it could negatively impact the small number of women who plan home VBACs by requiring them to have a VBAC consult with an OB.

So, what is the right decision?

Support this bill so CNMs can have a greater reach?

Or oppose this bill because of this requirement?

My mission is to increase access to VBAC in all birth settings. Is it enough that this may increase hospital VBAC access – where most women birth – as well as birth center VBAC while possibly making home VBAC harder to achieve?

Here is the specific language from AB 1306 (Sec 6, 2746.5(B)):

If a woman wants a home VBAC and she ‘still desires to be a client of the certified nurse-midwife, the certified nurse-midwife shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A certified nurse-midwife may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and, based upon review of the client’s medical file, the certified nurse-midwife determines that the risk factors presented by the woman’s condition do not increase the woman’s risk beyond that of a normal, low-risk pregnancy and birth. The certified nurse-midwife may continue care of the client during a reasonable interval between the referral and the initial appointment with the physician and surgeon.’

This is why I’m conflicted:

44% of CA hospitals outright ban it. They do not “allow” their physicians to attend VBAC. What happens if those hospitals decide, they will not “allow” their physicians to even consult with families seeking out-of-hospital (OOH) VBAC? Or physicians say that their malpractice insurance will not “allow” them to consult with OOH VBAC families? Where does that leave OOH VBAC families?

Right now, the VBAC rate in the state of California is only 9%. This bill could increase VBAC access in birth centers and hospitals assuming that hospital policy “allows” CNMs to attend VBAC.

As it stands, 91% of California families have repeat cesareans and the overwhelming majority of those are due to VBAC bans, misinformation and being unable to find a supportive provider.

But here’s the tough part: OBs who are staunch supporters of VBAC have told me that they would never have a consultation with a woman planning a home VBAC because they don’t, in any way, want to be connected with something that could be construed as validating, okaying, or approving home VBAC.

Even though the legislation isn’t asking OBs to approve of home VBAC, that is what OBs see. And the overwhelming majority of OBs – who support hospital VBAC and may even philosophically agree with OOH VBAC – would not participate in VBAC consults for women planning home VBACs.

This is mitigated a bit by the fact that women can have these consults via a chart review and Skype. So regardless of where they live in the state, they could reach the handful of OBs willing to participate in a VBAC consult.

But having the VBAC consult in the legislation means that as OB allies die, or as hospital policies tighten, or malpractice insurance fears increase, the legislation holds firm. That is not a good thing. It leaves women standing out in the cold on their own. And forces them to go back to the hospital system, where, as we see from the current California VBAC rates, they will likely acquiesce to a cesarean or be forced into a cesarean per hospital policy that is presented as equivalent to law unless CNMs are able to measurably increase VBAC access in the hospital setting.

CNMs can tell families that the prior cesarean is “unlikely to impact this pregnancy” and then talk about the unlikely though possibly dire consequences if a uterine rupture occurs out of the hospital. And talk about transfer protocols as you would with any other patient. Women don’t need to talk to an OB in order to get that information.

So while this bill does include home VBAC in the language, access to home VBAC is assuming that the pregnant person can find a OB who is willing to provide them with this consult. While the option is there, the ability to exercise that option is based on the kindness and ethics of a few OBs. And when they are gone, or the climate changes, women bare the brunt of their absence.

A VBAC consult does not make pregnancies safer. It will not improve outcomes. It only undermines the professional training of CNMs and the autonomy of patients.

And all the while, this bill also removes physician supervision from CNMs. And that is a very good thing.

So, do we say to home VBAC families, “Best of luck to you?” and, “Removing physician supervision for CNMs is worth this trade?” and then hope and pray that these women can find an OB willing to provide them with this consult?

I’m sharing with you the pros and cons as I see them so you can make your own decision.

It’s not too late to contact your state Senator and tell them, “I’m calling to voice my support of [or opposition to] AB 1306.”

Does your state require families planning home VBACs to have a consultation with an obstetrician? If yes, I’d like to ask you a few short questions.


Update Friday August 19, 2016 10:21pm

Thank you to those that contacted your Assembly Member today! The deadline to amend the bill to exclude the VBAC consult was Friday.

The next step is to oppose the Senate floor vote which is expected to happen next week (the week of Aug 22nd).

Please contact your state Senator on Monday, August 22nd, and tell them, “I’m calling to voice my opposition to AB 1306.” That’s it.

If you click the yellow button below, I’ll send you a reminder email Monday morning when the capital opens at 9am.

Be notified when legislation threatens VBAC access!


August 18, 2016 by Jen Kamel

Yesterday I was in Sacramento attending the Midwifery Advisory Council meeting at the California Medical Board.

At that meeting, I learned about a piece of legislation that will decrease VBAC access in California.

TODAY IS THE LAST DAY TO VOICE YOUR OPINION!

If access to midwifery care for women who have had a prior cesarean section is important to you, then please register your opposition to AB 1306 unless amended to exclude VBAC consult with your Assembly Member or with it’s author – Assembly Member Autumn Burke.

AB 1306 would remove physician supervision for Certified Nurse Midwives (CNMs).

This is a good thing.

But here’s the bad part: it puts into statute (law) a requirement that any woman seeking to deliver with a CNM outside a hospital AND who has had a prior cesarean delivery must first have a consultation with a physician (AB1306 Sec 6, 2746.5(B)).

Be notified when legislation threatens VBAC access!

It is this requirement for consultation that is at issue for the following reasons:

• All women are capable of determining for themselves and their families, together with their midwife or health care provider, what measure of risk is appropriate for them. Requiring a physician consultation before they are able to continue midwifery care undermines patient autonomy.

• Certified Nurse Midwives (CNMs) are highly trained health care professionals. They are quite able to determine, together with their client, when a particular woman would benefit from a consultation with a physician.

Requiring a physician consultation for every woman with a prior cesarean delivery does nothing to increase her safety in the current pregnancy. There is no way for a physician (or anyone else) to predict which pregnant woman is going to have difficulty with her current birth because she had a cesarean delivery in a prior pregnancy.

Requiring a physician consultation puts an increased burden on women. It may delay prenatal care, a known risk factor for prematurity, low birth weight and poor outcomes. It is costly and time consuming in the absence of evidence for benefit.

While collaboration between care providers is the ideal, in many areas of California midwife/physician collaboration is not possible because there are no physicians willing to form this relationship. This reduces access to midwifery care and in many instances it also reduces access to successful vaginal birth after a prior cesarean.

Putting precise wording, regarding any medical condition, into statute disallows health care providers the use of the most recent research when helping clients make decisions regarding their care. Putting into law, the requirement for a physician consultation when a woman has had a prior cesarean delivery, will not allow women and their midwives to take into account the growing body of evidence surrounding the practice of a trial of labor after a previous cesarean (TOLAC), prior to determining the need for a physician consultation.

I fully support CNMs and the important care that they provide to California families. But this bill is problematic because of how it will impact VBAC access for those who want an out-of-hospital VBAC with a CNM.

Once again, call your Assembly Member or AB 1306’s author – Assembly Member Autumn Burke – TODAY and say, “I’m calling to voice my opposition to AB 1306 unless amended to exclude VBAC consult.” That’s it.

If you want to say more, you can add, “…because it restricts a woman’s right to choose her care provider and mode of delivery.”

I already called my Assembly Member and it took me exactly 36 seconds.

I hope you do the same.

If you live outside of California, please leave a comment on the author’s Facebook page so others who are learning about the bill realize the implications it will have on VBAC access unless amended.

Be notified when legislation threatens VBAC access!

Home VBAC threatened for California families

There has been a lot of confusion regarding AB1308, the legislation that went through at the beginning of this year in the state of California. It said that LMs were no longer allowed to attend home births some situations (such as breech, beyond 42 weeks gestation, etc) and other situations required a physician to sign off on the home birth.

It’s these regulations that are currently being written by the Medical Board with input from ACOG, CAM, CFAM, and VBAC Facts. It is under discussion whether a prior cesarean should be included on this list of conditions that would necessitate a physician’s approval in order for the woman to plan a home VBAC.

On October 15, 2014, I flew to Sacramento and attended a Interested Parties Meeting at the California Medical Board.  I spoke on behalf of California women who want home VBAC to remain an option in our state. You can read a summary of that meeting here and listen to a partial recording of the meeting here.

There is going to be another meeting on December 15th from 1-4pm in Sacramento (agenda) and I will be there once again representing consumers.  I will be preparing a short testimony.  If you are a California resident and would like to attend the meeting, please do.  If you can’t, but want your voice to be heard, please email me the following information:

1. Why home VBAC is important to you

2. Your name

3. Your county

More information from the California Association of Midwives and California Families for Access to Midwives

 

Florida law mandates that insurance covers homebirth

Found this blog where another woman uses Florida law to get her insurance to cover her homebirth.

Here is Florida Statute Number 627.6574, but it’s section 7 that spells it out very clearly.  I’ve bolded it for your reading pleasure….

1) Any group, blanket, or franchise policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.
(2) Any group, blanket, or franchise policy of health insurance that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.
(3) This section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by an insurer.
(4) Any group, blanket, or franchise policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician’s office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.
(5) An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process that includes a written protocol for utilization review and quality assurance.
(6) An insurer subject to subsection (1) may not:
(a) Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section.
(b) Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.
(c) Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.
(d) Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(e) Subject to paragraph (7)(c), restrict benefits for any portion of a period within a hospital length of stay required under subsection (2) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.
(7)(a) This section does not require a mother who is a participant or beneficiary to:
1. Give birth in a hospital.
2. Stay in the hospital for a fixed period of time following the birth of her infant.
(b) This section does not apply with respect to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.
(c) This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (2) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.