Rigid Physician Supervision Requirements Impede Care for Home Birth Families

Sandy Glenn, LM MBC
Feb 13, 2016
4 min read

In regard to DHEC’s proposed new regulations revisions for hospital based physician approval for all moms planning home delivery, the following are my concerns about the restrictions. . Learn more about DHEC proposed new restraints at: http://www.scnacpm.org/call-to-acti...

502. Prenatal Care

"A. The midwife shall, upon acceptance of a woman for care, require her to have two (2) visits with a physician, with obstetric admitting privileges at a South Carolina hospital. One of these visits must be in the final six (6) weeks of pregnancy. A physician shall make a written determination that the planned birth is low risk. The midwife shall make entries in the patient’s record of the physician visits."

These proposed revisions have numerous problems:

1) If DHEC is going to provide a regulation, they should also provide the means with which to comply with the regulation. I have personally made contact with every known member of the DHEC OB Task Force medical offices and Dr. Bullard, DHEC staff OB. None of them were able to provide the services proposed in the regulation revision.

I have contacted my local health department Family Planning and WIC offices and they were staffed by APRN's who would not qualify under the conditions of the proposed regulation.

The current regulation states: "1. Required Visits. The midwife shall, upon acceptance of a woman for care, require her to have two visits with a physician, community health center or health department. One of these visits must be in the final six weeks of pregnancy. The midwife shall make entries in the patient's record of the physician, health center, or health department visits."

While the current allowance of maternity "HEALTH DEPARTMENT VISITS" for women desiring Licensed Midwife care, may not currently be the only option for some women in SC, at least the current regulation allows for clinic visits so that all SC women have access care. If the proposed regulation revision is adopted, DHEC will not be ensuring that the public needs are met.

Requiring women to find physicians with OB admitting privileges is not a reasonable rule or regulation.

2) I have found a small percentage of hospital based physicians who would both qualify and be willing to provide the proposed regulations revisions. But on every occasion their affiliated hospital disallowed them from providing the service.

Although EMTALA mandates ( The Emergency Medical Treatment and Labor Act) that a public hospital accept all pregnant women in labor, it does not require that the hospital provide prenatal risk assessments. If DHEC wishes consumers to be able to find a hospital based physician, the burden of the regulation MUST BE ON THE HOSPITAL. If it is the belief that a collaborative arrangement between a physician with OB admitting privileges and a Licensed Midwife is the best interest of the public (there is no evidence to support this theory), then DHEC should require the hospitals to supply the care. It serves no purpose to require the consumer or the Licensed Midwife to find services that do no exist. The burden of regulation must start with the hospitals.

3) By requiring a physician to make a written determination that a planned home birth is low risk, DHEC is creating a Medical Malpractice nightmare for the physician or his affiliated hospital. The physician has not visited the home of the family or discussed transfer options with local EMS. A written statement from a physician creates a deep pocket that could make him a target for litigation. It is unlikely that a physician with OB admitting privileges would be covered under his medical malpractice insurance if he were to provide such documentation, but if he were covered, the cost for coverage would certainly increase.

4) Many states only require physician consultation when deemed necessary by the CPM or for prescriptions required for delivery. Since a midwife is trained and required to be able to identify the signs potential problems during pregnancy and birth, these mandatory physician meetings are redundant and impose an unnecessary financial burden on the consumers.

I recommend that the Depart adopt new regulations such as the statue or regulations from Wisconsin. I am attaching those links. Wisconsin has collaborative care that is both feasible and safe for the mothers and babies of that state. It allows Certified Professional Midwives to practice within the full scope of their training without putting the burden of risk determination on a physician or affiliated hospital. In order to be functional, the rules may not do any of the following:

(a) Require a licensed midwife to have a nursing degree or diploma.
(b) Require a licensed midwife to practice midwifery under the supervision of, or in collaboration with, another health care provider.
(c) Require a licensed midwife to enter into an agreement, written or otherwise, with another health care provider.
(d) Limit the location where a licensed midwife may practice midwifery.

http://docs.legis.wisconsin.gov/code/admin_code/sps/professional_services/180/182.http://docs.legis.wisconsin.gov/statutes/statutes/440/XIII/9805

I am also attaching a similar statement from the FTC with regard to APRNs in SC:

“rigid supervision [and collaborative agreement] requirements may impede, rather than foster, development of effective models of team-based care.” Rigid collaborative practice requirements “can arbitrarily constrain this type of innovation, as they can impose limits or costs on new and beneficial collaborative arrangements, limit a provider’s ability to accommodate staffing changes across central and satellite facilities or preclude some provider strategies altogether.” https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-south-carolina-representative-jenny.horne-regarding-house-bill-3508-3078-advanced-practice-registered-nurse-regulations/151103scaprn.pdf

I propose that 61-24 502 be eliminated and 61-24 601 be changed to read:

CONSULTATION AND REFERRAL.

(a) A licensed midwife shall consult with a licensed physician or a licensed certified nurse midwife providing obstetrical care, whenever there are significant deviations, including abnormal laboratory results, relative to a client’s pregnancy or to a neonate. If a referral to a physician is needed, the licensed midwife shall refer the client to a physician and, if possible, remain in consultation with the physician until resolution of the concern.

Section 602 and the remainder of the regulation should mirror this language.

http://www.scnacpm.org/call-to-action/

#saveSCmidwives

#NikkiHaley fix this

#DHEC