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Indiana midwife debate headed for another round: Committee to study issue; bill set to be reintroduced

July 17, 2006

A bill that would give women what some say is their right to choose where and how they can give birth has been incubating in the state's General Assembly for eight years.

But hopes are running high for the proposed law that would regulate and expand midwifery in Indiana because it will be studied by a special committee this summer for a possible reintroduction in the 2007 legislative session.

Under current Indiana law, only doctors and registered nurses are able to act as midwives.

Those who oppose the bill, authored by Rep. Peggy Welch, a Democrat from Bloomington and a nurse, say only licensed nurses and physicians should deliver babies, and do so in medical facilities-not the home-for safety reasons. "The general concern is safety," Welch said. "But a good midwife is not going to take on a high-risk patient. I don't think if we had this law, there'd be some huge explosion of home births."

The law would establish a midwifery board to license what are called certified professional midwives.

CPMs receive pregnancy and childbirth training through academic study and clinical apprenticeships. They are certified through the North American Registry of Midwives, or NARM, after an assessment of their skills and a written exam.

Welch's law, which has made it through the House twice but never the Senate, has been revived partly due to recent charges against unlicensed midwives.

Most recently, Jennifer Louisa Williams of Bloomington pleaded guilty last month to practicing midwifery without a license, a felony in Indiana.

Charges were filed against Williams, who has been certified by the North American Registry of Midwives, following an investigation into the death of a newborn she helped deliver. Williams was not charged in the baby's death.

Indiana is one of 10 states with laws restricting midwifery. It does not allow a CPM to deliver babies at home or elsewhere.

While a licensed nurse or doctor can deliver babies at home, most choose not to.

"It's a philosophical difference in opinion," said Welch, who taught Lamaze childbirth classes before becoming a nurse. "I understand that, but there are many families choosing this anyway."

Records about home births in Indiana are hard to come by since midwives here are reluctant to stand up and be counted.

Similarly, credible data of home births nationwide is not available, although the National Center for Health Statistics tracks births in and out of hospitals-which includes birthing centers-and by whom.

In 2003, midwives delivered 8 percent of all babies born that year, according to the center's most recent statistics. That's double the figure in 1990.

Welch estimates 1,000 Indiana families each year choose to have their babies at home.

"Women are doing this despite the legality of it," Welch said.

So the current law helps drive midwives underground and creates a more dangerous situation for mothers, Welch and others say.

"Licensing midwives would clarify the qualifications of the attendant in homebirth situations," said Mary Ann Griffin, president of the Indiana Midwifery Taskforce, which backs Welch's proposed law. "We're asking for regulation so consumers know who they're hiring because, as it stands, it's happening now by non-CPMs."

Opponents say including NARM-credentialed health care practitioners in the pool of those who can deliver babies is dangerous.

"We like the model where the midwife is a nurse because that brings specific expertise to the birthing experience," said Kevin Burke, president of the Indiana State Medical Association. "NARM allows a person with less training to perform midwife duties."

Burke, an internist who practices in Clark County, admits the hospital labor and delivery experience isn't as comfortable as it should be, but said the law as it stands also protects the hospital physician.

A mother who is having complications during a home delivery might be brought to the hospital, Burke explained. That puts a doctor in the position of administering care to a patient he has not seen before.

"Is it fair to a physician who is later thrown into caring for a high-risk labor patient?"

Burke also admitted that medical intervention in home births is lower than for those in a hospital. He did not disagree with a 2005 British Medical Journal study that found women who planned home births, but were later transferred to a hospital, had lower rates of medical intervention, such as Caesarean section, than those who planned to have their babies in a hospital from the start.

He pointed out that the findings aren't unexpected.

"Healthier women are more likely to plan to deliver at home, so the better stats in that regard are not surprising," he said. "Are there deliveries that can be done safely at home? Probably. But we can't predict who these women are. Low-risk pregnancies can turn into high-risk labor on a dime."

Which is exactly why the law is needed, Welch and Griffin said.

"Right now, I could read a few books, watch a few home births and call myself a midwife," Welch said. "That's scary."

But because the law would regulate a midwife's training and credentials, the emergency room doctor would be more aware of what kind of care the mother-tobe had received to that point.

And because the law would legalize the practice of midwifery in Indiana, there'd be no fear on the part of the midwife to transport the mother to the hospital, Griffin said.

The law would also provide a lower-cost option for mothers and likely expand insurance availability for those who want to have their babies at home.

Generally, insurance companies cover midwife care, provided the midwife is licensed under state law and works in a hospital or approved birthing center.

That's how it works for Anthem Blue Cross and Blue Shield in Indiana, a subsidiary of Indianapolis-based WellPoint Inc., according to company spokesman Tony Phelps.

Anthem contracts with fewer than 10 licensed midwives in Indiana and there are not a lot of claims, Phelps said, although exact figures were not immediately available.

So while Welch is reluctant to predict the chances for success for her bill with its recent revival, she's cautiously optimistic.

"Women choose to have their babies at home for lots of reasons," Welch said. "Because it's cheaper or for religious reasons. There's less medical interference. At a basic level, it's the woman's right to choose how to have a baby. So we'll just keep educating people and trying to get the law changed."
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