Recap: Interested Parties Meeting 

The leadership at California Association of Midwives held a conference call on Sunday morning to clear up some of the confusion. They explained that many of the information regarding the meeting was either false or blown out of proportion, and that the intention of the Interested Parties Meeting was to clarify the current regulations for midwives as required by statute and reach consensus. This was a normal part of the legislative process and had been expected by the leadership at CAM.

Draft Regulations Spark Further Concern

Unfortunately, things got more tense and confusing yesterday (Tuesday) regarding a link to proposed regulations for Licensed Midwives. The first list in the document enumerated preexisting maternal diseases or conditions likely to affect a pregnancy. In addition to many of the conditions previously listed in the Practice Guidelines for California Licensed Midwives, other conditions included:
 

• History of uterine surgery including prior cesarean section (the PGs for LMs do not specify prior cesarean, only "invasive uterine surgery" which can be interpreted as hysterotomy, myomectomy, or other surgeries)
• History of three consecutive spontaneous abortions
• History of cervical cerclage
• Previous unexplained neonatal mortality or stillbirth
• History of postpartum hemorrhage requiring transfusion
• Prior fetal structural or chromosomal abnormality
• History of pre-term birth
• History of IUGR
• History of severe postpartum hemorrhage
• History of eclampsia, severe pre-eclampsia, or HELLP
• History of gestational diabetes
• No prenatal care prior to third trimester
• Current or significant history of alcoholism, alcohol abuse, drug addiction, or drug abuse
• Age 35 years or older at delivery

More rumors flew; some folks said that the CAM leadership had already negotiated on these items and they would be added to the regulations at the meeting this week. That as many people as possible were needed at the meeting to provide their input to save HBAC. I didn't know what to believe.

Another message from CAM leadership followed last night, saying they would be meeting with the Medical Board of California prior to the Interested Parties Meeting in order to hash out some of the details, and that the "laundry list" of proposed regulations were merely talking points; nothing had been set in stone. The list was a compilation of pieces of other states' regulations for midwives, and the Interested Parties Meeting would be an important time for CAM to get more clarification and provide input on the list.

Meeting Highlights

The meeting was held today from about 12-5pm, lasting an hour over the expected window. Many professionals had the time to speak about their feelings and concerns. I've basically collected some of the most interesting things I heard, but for an official record of the event please check the Medical Board of California web page; I assume they will have minutes online. [CAM editor note: the meeting is typically available as a webcast and is posted within a week. We'll make this available to you once it becomes live.]
 

• Carrie Sparrevohn, LM and Chair of the Midwifery Advisory Council, gave a brief history of the Standards of Care for midwives, which were developed and finished in 2003. She said that at the time these were created, practicing midwifery with physician supervision was required by law however no physicians would supervise midwives (as was the case until AB 1308 passed at the end of last year). Therefore, the Standards of Care were devised as practice guidelines for midwives assuming no physician supervision was available, and therefore were conservative in what midwives were "allowed" to do. Given that circumstance, the SOC were adopted through consensus between the California College of Midwives, California Association of Midwives, American Congress of Obstetricians and Gynecologists, and California Association of Licensed Midwives and allowed for LMs to attend VBAC provided they have the client sign an informed consent document. Sparrevohn proposed that the SOC from 2003 be used in defining the regulations rather than "re-inventing the wheel," and asked why, if it was ok in 2005, is VBAC now necessitating a referral to a physician for consult?
  Constance Rock, LM from CAM as well as Lesley Nelson, LM both voiced support for this idea. The MBC representative said that ACOG representatives had raised concerns regarding using the original Standards of Care. 
  Tosi Marceline, LM and member of the Midwifery Advisory Council, also agreed that using and editing down the Standards of Care would be more beneficial than adding vast sections to the regulations. She also indicated that it seemed that if the Medical Board could no longer require physician supervision, supervision with legislation seemed to be happening. She noted it was somewhat degrading for Licensed Midwives to be told they need permission to care for clients and do not possess the adequate judgment to know when to refer care to an obstetrician. She also noted that if clients do not comply with a referral for collaboration, the Licensed Midwife would be effectively forced to abandon the client as she can no longer provide care under the regulations and statute.
• Medical Board of California's legal counsel Kerrie Webb said that the reason the regulations were being worked on is because the statute (effective January of this year) requires regulations be set. She also noted that starting with the Standards of Care in no way guarantees that the goals for Licensed Midwives will not be derailed. She said that once the regulations were worked through, a change to the Standards of Care may be necessary as well, however regulations trump Standards of Care/Practice Guidelines. That is to say, if a Licensed Midwife is given a choice between following the regulations or the standards of care, the regulations hold more legal precedence in cases of examination from the Medical Board. The two should reflect one another though.
• Webb then showed us a list of proposed initial revisions (also not set in stone) she had gone through with CAM. Shannon Smith-Crowley from ACOG said that ACOG had not been part of this process and had not seen even the original list or revisions until the meeting today. She wanted to be clear that not all items on the list were from ACOG or its representatives. The proposed revisions included the following:
  • History of uterine surgery including prior cesarean section (the PGs for LMs do not specify prior cesarean, only "invasive uterine surgery")
  • History of three consecutive spontaneous abortions
  • History of cervical cerclage REMOVED and "Cervical incompetence" ADDED
  • Previous unexplained neonatal mortality or stillbirth
  • History of postpartum hemorrhage requiring transfusion REMOVED
  • Prior fetal structural or chromosomal abnormality
  • History of pre-term birth REMOVED
  • History of IUGR
  • History of severe postpartum hemorrhage
  • History of eclampsia, severe pre-eclampsia, or HELLP
  • History of gestational diabetes
  • No prenatal care prior to third trimester REMOVED
  • Current or significant history of alcoholism, alcohol abuse, drug addiction, or drug abuse
  • Age 35 years or older at delivery REMOVED 

• Dr. Kelly McCue, a practicing physician from ACOG, delineated the benefits and downsides to having a list of broad reasons to consult with a physician versus the extremely specific Standards of Care. Benefits were that they could be interpreted freely, however downfalls were that they could be interpreted freely in the instance of examination from the Medical Board as well.
• Alison Osborne, LM talked about the original "Laundry List" of reasons to refer out created by the Bay Area Guild of Midwives, which included referrals for any clients under age 18 or over 40. She reported the midwives got rid of the sections regarding age fairly quickly. She also talked about the impact of AB1308 (the new law) on her area, and said since January one breech baby and one set of twins were born unattended because the client could not have a Licensed Midwife present and did not want to seek obstetrical care. She also said that in Placer county there are no OBs who will endorse VBAC at home. She noted "the accommodation of choice is necessary" in creating these regulations so as to preserve patient safety.
• Faith Gibson, LM also reported that many OBs to whom she has sent clients (Kaiser specifically) have said they will never write down that VBAC is ok.
• A long conversation occurred regarding the risk of a poor outcome of a Licensed Midwife attending mothers with pre-existing conditions. The language of risk was heavily discussed ("what does 'Likely' mean? 5%? 10%? Greater than 50%?), as well as the different risks a woman may experience at home compared with a hospital regarding VBAC and timely hospital transfer and surgery in the case of a uterine rupture as well as managing the pregnancy of a woman who experienced complications in previous pregnancies. Dr. McCue said "We know you can run across the freeway and not get hit," comparing a Licensed Midwife attending the birth of a woman with a previous (that's previous pregnancy) case of pre-eclampsia to running across a freeway. Faith Gibson said that it is a matter of possible vs. probable, and that no midwife would attend a birth if a bad outcome was probable. Sarah Davis said that in AB1308, the terminology of "high risk" was replaced with "likely to affect" the pregnancy, and that "likely to" is more specific than "may."
• Sarah Davis proposed that the items containing "history of" should be considered if they left an anatomical change in the woman (such as a cesarean scar).
• Sparrevohn asked repeatedly if the regulations could be constructed in a way that a woman is benefited by consulting with a physician per regulation. She asked Dr. McCue "what is gained if we refer?" for cases of previous postpartum hemorrhage, or previous congenital abnormality? How does the care change for a woman seeing an OB vs. a Licensed Midwife, and is that change beneficial to the client?
• HBAC was a big discussion (obviously). 
  • CAM flew in Jennifer Kamel from VBACFacts to give a statement about the safety and accessibility of VBAC and the impact of requiring LMs to refer their clients for consultation and sign-off. She said that in combination with restrictive VBAC policies in hospitals (44% of hospitals ban VBAC in California and many more that provide misleading informed consent documents with overplayed risks of VBAC, or forced cesareans), stricter regulations would cut off care for many women wanting VBAC and would drive them to either have unwanted, unplanned cesarean deliveries or unattended births at home (which carry far higher morbidity and mortality rates than planned home births with midwives). She also drove home the fact that complications of repeat cesarean births including placenta accreta and hysterectomy are routinely underplayed by physicians and that a short interval between births does not preclude someone from having a VBAC.
  • Diana Vallarta, LM read a short statement from ICAN that said the organization agrees with the National Institute of Health's statement that VBAC is a responsible and safe choice, and that women should be empowered to make choices for themselves. ICAN supports changes in maternal healthcare that encourage the empowerment of women.
  • Tosi Marceline asked "when does someone stop being a VBAC? If she's had a previous VBAC and this is her second? Third? Fourth? Fifth? Do you ever stop being a VBAC? How many vaginal births does it take?"
  • Shannon Smith-Crowley said that in the formation of AB1308, VBAC was left for physician consult due to the high variability of reasons for the primary cesarean. ACOG would have preferred a blanket ban, but Susan Bonilla (who authored AB1308) was committed to preserving HBAC. The physician consult was the only acceptable compromise for ACOG. She further said that ACOG had never wanted HBAC to be legal, but let it go through originally and allowed LMs to waive their scope of practice in order to attend VBACs, knowing it would get ACOG to the table when the LMPA was under sunset review in 2013. 
  • Sarah Davis, LM said that CAM has never agreed with ACOG regarding HBAC. She said that according to a practice guideline released from ACOG in 2010, TOLAC for 1 or 2 prior low transverse incisions is acceptable and should be encouraged, given that "immediately available anesthesia and OB are available." She said that the lowest level (C) quality of evidence informed the practice bulletin, and that anecdote, routine, and habit should not solely shape recommendations for location of TOLAC.
    Kamel also pointed out that "immediately available" was never defined however is widely interpreted to mean 24/7 on-site availability, despite 1/3 of hospitals with VBAC bans having such availability.
  • Webb asked if there were any states in the US allow LMs to attend HBACs without physician consult. Sarah Davis named a few including Vermont, New Mexico, and Oregon, and there were a few more she was unsure about.
• Karen Ehrlich, LM talked about the Licensed Midwife Annual Report as a valuable tool for calculating outcomes for planned home births. She said that in about 13,500 planned home births, most delivered at home. Of those who transferred to a hospital, <8% had sequelae lasting over 6 weeks. There were a total of 180 adverse events, which included adherent or retained placenta, and hemorrhage.
• Constance Rock asked Dr. McCue what the point is of referring to an MD, someone who does not specialize in home birth, to determine if a home birth is a good choice? She suggested this alone is taking away a woman's choice.

The meeting was cut short and there is talk of having another Interested Parties meeting or otherwise continuing the conversation at the MAC meeting in November.