Updated: Jun 23, 2021
Midwives are demanding EQUAL ACCESS TO HOSPITAL DOORS and a SC statute to protect the profession. Since November, 2017, the Midwifery Advisory Council and other midwife organizations have been urging South Carolina's Department of Health and Environmental Control (DHEC) to repair dangerous errors in a hospital regulation. Over the past three years, midwives have worked diligently to resolve the issues of being denied Equal Access to Perinatal Levels of Care. In addition to streamlining and expediting care in the event of an emergency, adding the midwives to the Levels of Care would automatically give midwives and birth centers access to consultative, outreach, support services and professional continuing education.
DHEC continues to delay making changes to a regulation that does not give midwife patients equal access the levels of perinatal care and forbids level II hospitals from accepting ‘outborn’ babies. In short, DHEC updated hospital regulation 61-16 and listed every maternity care provider in South Carolina EXCEPT midwives and birth centers (including prison infirmaries). ALL other maternity providers get streamlined care when an emergency occurs, but hospitals are only required to give midwife patients minimal EMTALA emergency room access (Emergency Medical Treatment & Labor Act).
Additionally, the negligent regulation is in direct conflict with SC 2020 Appropriations Act Part 1B SECTION 34 - J040 - 34.46 which requires that ALL hospitals act in good faith to coordinate transfer agreements with EVERY midwife attended Birth Center within a 50 mile radius. Freedom of information requests made to DHEC, revealed that EVERY SC Licensed birth center was advised of their requirements regarding the Act each year since 2015, but that DHEC had never contacted any of the hospitals regarding the same compliance. Such delays in care could mean the difference between life and death, but DHEC continues to make excuses for failure to update their regulation. It has been three years since the Midwifery Advisory Council (MAC) first officially notified DHEC of their oversight.
Lori Gibson, Licensed Midwife and MAC Chairperson, poignantly expressed her concerns regarding DHEC’s lack of action,
“When you’re providing care to women and babies and if we’re getting turned away at hospital doors because they don’t see us as a provider; that’s an issue. Some children that have been turned away at the door are now two or three years old… since we’ve been working on this.”
In June 2018, after being informed of the issue, Governor McMaster’s office through Cindy Ledbetter, Office of Ombudsman, created an Intranet Quorum to resolve the error (Casework #: 809918). Initially DHEC responded favorably. Bently White Esq., Counsel for DHEC Health Regulations addressed the error in an email; “We want to ensure a holistic solution for addressing perinatal levels of care that involves the relevant parties. Our goal is to bring together you and all of the other stakeholders for productive dialogue on how best to affect changes based on best practices… The concerns you raised will require extensive discussions to determine the best path forward to support the whole perinatal system of care. We will conduct legwork to bring the parties together, and keep you informed regarding next steps.” Despite repeated request for updates and the resolution, no further communication has occurred on the quorum.
DHEC has proposed that instead of having direct access to the receiving providers at the hospital, the midwives must surrender the women and children in their care to an EMT who will relay necessary reports to the hospital instead of allowing direct access for provider-to-provider information. This additional step in the transfer process hinders proper communication during times of critical care. To our knowledge, no hospitals or emergency management services were invited as stakeholders and none appeared at the DHEC hearings.
The regulations proposal also required Licensed Midwives to call "911" if a woman declines any recommendation by a Physician or other Authorized Healthcare Provider during a Medical Consultation. A regulation requiring a midwife to call authorities and deny patient choice and autonomy could be considered a human rights violation and is a direct contradiction to the midwifery model of care.
The November 2020 DHEC Board hearing on the proposed regulation lasted over eight hours and ended with The Board asking the agency to correct or justify four major safety concerned brought up repeatedly during testimony by Licensed Midwife professionals and consumers:
Restriction on a widely used and necessary anti-hemorrhaging medication.
Restriction on access to Licensed Midwifery Care for all women who have had a previous cesarean section.
Restrictions on pain medications used for suturing repairs.
Equal Access to the Perinatal Levels of Care and the use of 911 requirements.
After the original hearing, DHEC proposed alternative language that were substantial changes beyond the original draft. The 'alternative' language put extreme restrictions upon the women who could deliver with a Licensed Midwife, required physician signed approval and co-management of care that removed the autonomy of Licensed Midwives. The regulation proposal would essentially puts Licensed Midwifery under the supervision of other professions not regulated by DHEC; therefore, the agency has no authority to require them to fulfill the mandates. Such extreme changes to a profession are not normally considered to be within the authority of DHEC or a government agency; but would traditionally ONLY be applied after the full process of creating a law with the approval of the SC House and Senate.
Substantive changes to a regulation draft after a formal hearing also require the agency to resubmit the proposal for another public comment period. Instead of allowing public comment on the final draft, the agency pushed the proposal on to the General Assembly where it will be reviewed by the Regulations Committee.
Although DHEC has been regulating midwives since 1971, there has never been a statute for their level of care. Without such a defining statue, Licensed Midwives have had ongoing conflict with the Department of Health regarding a standard Licensed Midwife scope of practice and safety protocols.
House bill H.3535, The Midwife Practice Act, comes not only as a result of the regulation disputes but also upon the recommendation of the Attorney General's office. The opinion statement addressing DHEC's authority over Licensed Midwives since there is no current law in place;
"We would suggest that the General Assembly further clarify the statutes involved to make it's intent clear...a statutory enactment may well be advisable in order to clarify the authority to regulate."
All of this is occurring while South Carolina Maternal Child Outcomes continue to receive failing report cards from the March of Dimes in the area of preterm birth rates. South Carolina recently received an 'F' grade for 2020, with declining trends since 2014. The Center for Medicaid Services (CMS) Smart Start research project has encouraged states to utilize more midwife-led birth centers to prevent preterm births.
The November 9, 2018 CMS Joint Informational Bulletin “found significantly improved outcomes among the [midwife attended] Birth Center participants. Given these results, states may wish to consider studying the availability of Birth Center care in their states… Given the long-term repercussions of preterm births and the maternal morbidity
and mortality risks associated with multiple cesareans, improved outcomes observed among Birth Center participants may offer health benefits and cost savings that are realized long past the infant’s first year." https://www.medicaid.gov/federal-policy-guidance/downloads/cib110918.pdf