New Mexico obstetricians are crying foul over an agreement forged by the state's human services department, several managed care organizations, and the state's midwives that will allow for Medicaid reimbursement for home births yet not require the midwives to carry liability insurance.

New Mexico has unusual parity in its numbers of midwives and obstetricians. According to the state Department of Health, there are 55 licensed midwives and 144 certified nurse-midwives in the state, a total of 199. According to the American College of Obstetricians and Gynecologists, there are 146 ACOG members (plus 51 junior fellows) in the state. In 1997, the New Mexico Medicaid program was privatized, and it's now run by managed care organizations (MCOs). The state requires that MCOs carry medical malpractice insurance, and MCOs in turn require the same of all their providers.

Midwives performing home births typically do not carry malpractice insurance. When that insurance is available, the cost is prohibitive, but few insurance companies are willing to write policies covering home births at any cost. It's not that there have been a large number of expensive claims, said Roberta Moore, maternal health program manager for the New Mexico Department of Health. Insurers simply don't see this market as profitable.

The new agreement provides for reimbursement of midwives provided that Medicaid-eligible women who choose to use their services acknowledge that they are aware of the midwife's lack of insurance and formally waive their rights to pursue legal again action against the state, the MCOs, or the midwife. The relatively small number of obstetricians in New Mexico and the state's rural character helped proponents of the agreement argue that it offers women in underserved remote areas access to care that they ordinarily would not have.

Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, doesn't buy this argument. In an interview, she noted that family physicians frequently perform births in rural areas of New Mexico where there are no obstetricians, so these areas are not really underserved. Those family physicians have mandatory malpractice insurance.

In addition, the agreement does not limit Medicaid reimbursement to midwives in rural areas. An Albuquerque-based midwife would receive reimbursement, even though there are many obstetricians in that city, Dr. Phelan pointed out.

Furthermore, there is a fundamental unfairness in allowing midwives to go without malpractice insurance while receiving about the same fee as an obstetrician does for a birth, Dr. Phelan said.

“When you're getting paid &dollar;1,200 for 9 months of care and a delivery, there are places where docs are having to deliver a hundred babies just to meet their malpractice [insurance premiums],” Dr. Phelan said, noting that with premiums of approximately &dollar;80,000 annually, New Mexico obstetricians are getting somewhat of a bargain, compared with colleagues in other parts of the country. New Mexico authorities basically treated the malpractice insurance problem “with an aspirin, which is to say [that midwives] are an exception to the rule and they don't have to carry insurance and they could still get paid. But they did not deal with the underlying problem,” which is the malpractice insurance crisis.

And she noted that when a home birth starts going wrong, mother and baby would be transferred to a hospital. Supposing the infant or the mother dies or the child has an ongoing deficit, “who's going to be sued?” Dr. Phelan asked. “It's the doctor who inherited a problem that was already in development, because he or she is the one with the malpractice insurance. We're the ones with the deep pockets, so we're the ones who are going to get dragged to court and have to spend days in depositions and in court going through all that emotional stuff on our own.”

The Midwives Alliance of North America (MANA), one of the two national midwifery associations (the other is the American College of Nurse-Midwives), said that it's true that midwives aren't sued very often, but the reasons are unclear. According to Diane Holzer, MANA's president and a licensed midwife, part of the reason may be that patients are more satisfied with their care or that midwives are able to develop more of a personal connection with their clients.

She noted that even in the nine states in which Medicaid reimbursement for home births technically is permitted, many midwives cannot actually receive reimbursement. California, for example, allows for Medi-Cal reimbursement of home births only if the licensed midwife is being supervised by a physician. But according to Ms. Holzer, not a single physician in California is willing to supervise midwives.

Why is that? “It's the question of the ages,” Ms. Holzer said in an interview. “The doctors all say it's a legal liability. They don't believe [home birth] is safe. But there are lots of studies out there that show that it is safe. I don't think that safety is the question if you take a look at the data out there. A lot of physicians have told us that their insurance companies have actually come out and said that if they back up out-of-hospital practitioners, they will be dropped.”

Physicians tend to be more accepting of nurse-midwives than of those without nursing degrees, Dr. Phelan said, adding that she has worked alongside nurse-midwives for 30 years, has helped train them, and is highly supportive of the use of nurse-midwives in birthing centers and hospitals. Some physicians may have the impression that someone can call herself a midwife after attending a 2-day workshop and participating in a handful of births. In reality, the requirements are more stringent. (See box, previous page.)

Despite the malpractice crisis that is causing many physicians to move away from obstetrics, the number of home births nationwide appears to be holding steady, Ms. Holzer said. “Birth is a natural process, and doesn't need to be interfered with to the extent that it has become in this country,” she added.

“I understand the reason why some women want home births,” Dr. Phelan said. “There is the perception of the rigidity of hospital settings, the unwillingness to have family in attendance, [the concern that] we're going to cut episiotomies, the higher rate of C-section, all of those kinds of things. But I think much of that has changed. … I think more and more hospitals are trying to have a more homelike birth experience with the ability to still provide the current technology and safety.”

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ELSEVIER GLOBAL MEDICAL NEWS

Midwife Classifications Defined

A Certified Midwife (CM) is an individual educated in the discipline of midwifery who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives. This term also is used in certain states as a designation of certification by the state or midwifery organization.

A Certified Professional Midwife (CPM) is a knowledgeable, skilled, and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives and is qualified to provide the midwifery model of care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings. CMs and CNMs typically practice in hospitals or clinics.

A Certified Nurse-Midwife (CNM) is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives. Unlike CMs or CPMs, CNMs are licensed in all 50 states.

A Direct-Entry Midwife (DEM) is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife typically provides care to healthy women and newborns throughout the childbearing cycle, primarily in out-of-hospital settings.

The term Lay Midwife is used to designate an uncertified or unlicensed midwife who was educated through informal routes such as self-study or apprenticeship rather than through a formal program. Other similar terms to describe uncertified or unlicensed midwives are traditional midwife, traditional birth attendant, granny midwife, and independent midwife.

A Licensed Midwife (LM) is a midwife who is licensed to practice in a particular jurisdiction (usually a state or province).

Sources: Midwives Alliance of North America; American College of Nurse-Midwives

Licensing Requirements in New Mexico

To be licensed as a direct-entry midwife in New Mexico, an applicant must complete 12 months of theoretical and clinical education at an accredited midwifery school, pass a licensing exam, and show evidence of the following clinical experience:

▸ Observing and managing 40 labors.

▸ Delivering 25 newborns and placentas.

▸ Completing 25 well-women health assessments.

▸ Making 100 prenatal visits with at least 15 different women.

▸ Starting one successful intravenous line.

▸ Performing 30 newborn examinations.

▸ Administering 15 uses of prophylactic eye medications.

▸ Making 30 postpartum visits with mothers and babies within 36 hours of deliveries.

▸ Collecting blood from 15 newborns for metabolic screening.

▸ Performing 15 6-week postpartum and/or yearly physical exams and Pap smears.

▸ Making 30 family planning visits, consultations, and/or referrals.

▸ Observing one neonatal-intensive-care nursery.

▸ Observing one high-risk obstetric-care case.

▸ Providing one complete series of prepared childbirth classes.

▸ Observing one complete breast-feeding information series.

These requirements apply to direct-entry midwives only; certified nurse-midwives are registered nurses with additional certification from the American College of Nurse-Midwives after 2 years of advanced training.

Source: New Mexico Department of Health

Medicaid to Pay Home-Birth Midwives in N.M.