Utah has a long history of midwifery as a well-respected profession. In 19th century Utah, midwives not only delivered babies, but often cared for any health care concerns of the citizens, since physicians were scarce. Midwifery was a calling in the early LDS church, and leaders sent midwives "back east" for extensive training. Utah had the best midwives in the country because of that commitment.
When the Medical Practice Act was written and codified in Utah law, it was not intended to limit or even affect midwifery, because midwifery was clearly considered a separate profession. Over the years, the laws of the state began to change as there became a distinction between the "Certified Nurse Midwife," who had medical training and licensing, and the "Direct-Entry Midwife," or "Lay Midwife," whose training is done outside of the nursing field.
Here's a tidbit of which my blog friends are unaware: I personally have had midwives for three of my births, and home births for two of these. My first child was born in 1985 with a CNM at Orem Community Hospital, my third child was born in 1988 with a lay midwife at home in Provo, and my fifth child was born in 1991 with the same midwife at my home in Fayette, Missouri. This woman was a second-generation midwife and part of a group of trained and competent direct-entry midwives then active in the Utah Midwives Association.
Shortly thereafter, in 1993, a statute which once excluded midwifery from the practice of medicine was quietly removed. Many lay midwives were not even aware of the change until October of 2000 when Liz Camp, direct-entry midwife in St. George was charged with four felony counts of practicing medicine without a license. These charges centered on two basic offenses: 1) using Pitocin to stop a postpartum hemorrhage and 2) cutting an emergency episiotomy. She faced 20 years (5 year max penalty for each of 4 charges). She plea bargained down to 2 misdemeanor counts of practicing medicine without a license, and received 18 months probation and a $250 fine.
Because midwifery had now been found illegal in Utah, The Utah Midwives Association formed a Legislative Committee to address the issue. Along with other home birth supporters they created a bill that legally defined direct-entry (non-nurse) midwifery. This bill was furiously opposed by the Utah Medical Association and the Certified Nurse-Midwives, and it took several years and many concessions to enact. Finally, the Direct-Entry Midwife Act was passed on May 2, 2005. Under this bill, direct-entry midwives were allowed to practice, perform prenatal care and to legally administer some few life-saving medicines if they certified with the state to do so.
However, the opposition by the medical field to lay midwifery continues. Last year (2007), the UMA introduced a bill to amend the Direct-Entry Midwife Act. The bill did not pass, but was sent to an interim committee for further study. The interim committee did not choose to study it because the bill is unnecessary given the excellent outcomes for Licensed Direct-Entry Midwives (2006, 2007). These reports show that midwives practicing in Utah are very safe, and consistently produce better results than hospital providers. Now the UMA has brought forth its second legislative attempt to re-write the circumstances under which a direct-entry midwife (licensed or not) can practice.
This year’s version (SB 93) is sponsored by Sen. Margaret Dayton, a former labor and delivery nurse. She says that she and the Utah Medical Association want to stop midwives from attending "high-risk" pregnancies that could result in the harm or death of baby or mother. The bill includes a myriad of restrictions that would exclude a woman from the care of a direct-entry midwife. Some of the exclusions are valid and already addressed in rules approved by DOPL (HIV positive women, premature babies, etc.). Most of them, however, are not. In fact, over 90% of the women who currently choose the care of a direct-entry midwife would no longer be able to qualify as "normal." The bill goes beyond the definition of normal birth, and is clearly a restraint of trade.
In just one example, multiple gestations, line 226, are precluded. One midwife writes:
This one really steams me. When you look at home born twins vs. hospital born twins you find a very drastic difference in treatment and outcomes! Home born twins are commonly born at term–many even go a full 40 weeks or longer! Home born twins are generally larger–some are even 8 or 9 lbs. each! Home born twins are born vaginally. Hospital born twins are commonly born prematurely. Sometimes this happens spontaneously, other times mothers are induced or c-sectioned early, often without a clear medical indication. This results in premature babies that could have been born as healthy full-term infants. Hospital born twins are usually much smaller as well, and suffer the complications small and early babies are subject to. Given this information, I would not at all feel comfortable giving birth in a hospital with twins unless they came prematurely on their own.
Also affected in the exclusions are women who have had miscarriages, women who have had infections during pregnancy, women with diabetes, women over 35, and women who have had previous cesaerean births. Utah Midwives Association President Jules Johnston said Dayton has gone overboard. "If they sneeze, they're risked out." SB93 also removes one of the midwife positions on the state midwife board and adds three members who are either a licensed physician or certified nurse midwife. There is one member of the public on the board.
Elizabeth Smith, CPM, LDEM, is very concerned about how SB93 has been presented. She writes:
The Utah Medical Association has very sneakily and dishonestly proposed a bill to the Utah Senate, much like last year's bill, that will take away the rights of most mothers to birth at home. At the Senate committee, both sides were ordered to work out a compromise. The UMA met with midwife representatives and came up with compromises to everything except a few items. Yesterday, the UMedA sent their own bill, without the agreed compromises to the Senate floor saying that it was the "Compromise" bill. They totally lied and all but one Senator bought it and voted for it. Now the bill SB93 has gone to the house to be voted into law.
Women of Utah have become very heated on the issue. An anonymous commenter said:
"The bill Dayton is trying to amend took a very long time to come to. It was a miracle the groups involved could come to such compromises and articulate boundaries that all sides could agree to and support. This is becoming a war on an idea, a promotion of personal feelings rather than fostering freedom and providing appropriate healthcare. No one should be forced into care another feels comfortable with but they, themselves, are not. A family should be supported in birthing at home, in the hospital, or in a birthing center without fear of stigma. It's time for Mrs. Dayton to remove her hands from the wombs of all the women in Utah and allow them to birth the way their studies and conscience determine. Women have proven to do whatever it takes to acheive what they're looking for. Scaling down this already thin bill allowing for freedom of choice may well increase the likelihood of traumatic outcomes because women who abhor hospitals could move toward unassisted birth rather than submit themselves to the perceived emotional and physical raping of their rights that they may fear. It's time to leave well enough alone."
I believe that our LDS emphasis on the family requires us to care about this and similar issues. My research has convinced me that midwife assisted home birth is safer than hospital birth. In many countries, home birth is considered the first choice for healthy women. The countries with the lowest mortality and morbidity rates are those countries where midwifery is an integral part of maternity care and where homebirth is commonly practiced. The home birth debate has been carried out in many places. I am aware of many studies which indicate that home birth is safer than hospital birth and that fewer complications occur at home (see, for example, the Mehl study. Feel free to link to other studies in the comments to this post.) If this is indeed the case, shouldn't Utah women maintain the legal right to have access to this service? Our Utah lay midwives are well trained and knowledgeable. They attend and assist in many more births than CNM's when they are undertaking their training. I feel that legislation should support what they are doing and assist them to become even more qualified in their field of specialization. We should not set them back in their efforts. Because of the excellent outcomes obtained by Direct-Entry Midwives, this bill seeks to solve a problem that doesn't exist.
SB93 has now gone to the House and is now going through several substitutions. I will be watching this issue carefully to see how Utahns will respond.