A practice on hold

Wednesday, July 18, 2007
Three months ago, April Pierce, left, served as a midwife to her sister-in-law and delivered her niece, Roseann Pierce. April's mother, Judy Pierce, right, also gave birth to four of her 10 children at home. (AARON EISENHAUER ~aeisenhauer@semissourian.com)

The medical association that filed a lawsuit challenging the language of a new Missouri law decriminalizing the practice of midwifery in the state is "cautiously optimistic" the judge will rule in their favor and strike down the statute.

The Missouri State Medical Association filed the lawsuit in Cole County Circuit Court, and Judge Patricia Joyce issued a temporary restraining order barring enforcement of the law until the Aug. 2 hearing, keeping the practice of home births illegal for now.

Despite the lawsuit, Bollinger County resident April Pierce hopes to begin practicing midwifery in Missouri this fall. Pierce went to Texas to study and practice midwifery and became a certified professional midwife. She has moved back to Southeast Missouri to be with her family. Four of her siblings were born at home after the first six children in her family were born in hospitals.

Philip Pierce, 13, Stephen Pierce, 10, and Joseph Pierce, 7, sat on the bed on which their mother Judy Pierce gave birth to them in their Bollinger County home. (Aaron Eisenhauer)

The Texas birth center Pierce worked at offered full care to expectant mothers, including lab work, sonograms and postpartum checkups. "That's what I'd like to open up here," she said.

MSMA argues that the inclusion of tocology, or obstetrics, in the bill violates the Missouri Constitution because it doesn't relate to the bill's original purpose, which was health insurance.

"Midwifery has nothing remotely to do with health insurance," said Tom Holloway, lobbyist with the Missouri State Medical Association.

Home births by a certified nursing midwife are legal in Missouri. A CNM must have a bachelor's degree in nursing, a two-year study in midwifery and a collaborative practice agreement from a physician in order to practice. The collaborating physician checks the patient charts provided by the CNM and approves or denies home births.

A home birth with the company of a certified professional midwife has been illegal in Missouri since the late 1950s. A certified professional midwife does not have a nursing degree but holds accreditation from the North American Registry Midwives. Missouri is one of 10 states that has prohibited the practice by CPMs. Until the June law, the practice of CPMs was a class C felony in Missouri.

Holloway said the association has no problem with the practice, just how it was legalized and the wording in the law, which says "any person who holds current ministerial or tocological certification by an organization accredited by the National Organization for Competency Assurance may provide services" as defined in the U.S. code for services relating to pregnancy.

NOCA accredits hundreds of organizations, including medical and other trade groups like the Examination Board of Professional Home Inspectors, the National Association of College Stores and the American Academy of Nurse Practitioners.

"Literally there are 200-plus bodies under that organization," Holloway said.

According to the law, hospitals would have to allow a person's chosen health-care provider to practice as long as the person holds a certification from NOCA. That may open the door for a person with any certification from an organization under NOCA, Holloway said.

"It's one sentence, and we think it's a very serious public safety issue. We think it's an endangerment to the public, and we want it stricken."

A 'flagrant case'

Holloway said a separate bill including appropriate licensure and regulated safeguards for midwifery should be brought before lawmakers separately instead of being stuck in the middle of a bill about health insurance.

"In our minds, this is a very flagrant case of violating the constitution," he said. "And at least in the first round, the judge agreed."

The precedent for cases relating to single-subject bills was the 1994 Hammerschmidt decision in which the Missouri Supreme Court ruled no language could be added to a bill that changed its original purpose.

"There's only been a very, very few cases that have upheld that," said Mary Ueland, legislative chair with the Missouri Midwives Association. "I think we have a very good chance at succeeding."

Ueland said bills have gone before lawmakers that detailed and regulated midwifery but said medical associations have always been able to find a senator to use a filibuster.

"What passed basically slid by the senator that had been filibustering," Ueland said. "Basically the lobbyists who were combing the bills were sleeping on the job."

Despite the manner in which the bill passed and the lawsuit filed against it, midwives and home-birth mothers in Missouri are relieved to have an apparent win for the practice.

Because the legality is so new and Missouri has virtually no state regulations for midwifery, Pierce said she would operate mostly by Texas regulations because that is where her experience was. "It has become far more of a profession than it used to be," she said.

CPMs are required to pass tests and skills assessments by the North American Registry of Midwives, the certifying agency under NOCA.

After qualifying, midwives must complete a one-year internship with 1,350 hours and deliver 40 babies while shadowing a senior midwife.

In Texas, Pierce had "all the basic equipment" for a low-risk delivery. She carried oxygen, medications for postpartum hemorrhaging, gloves, scales and blood pressure equipment.

"I did take IVs for rehydration also," she added. Midwives are trained to handle low-risk births with healthy mothers and small chance for complications. "They're not trained to handle high-risk births that should be under a doctor," she said.

Trumping hospital rules

Opponents of the Missouri law argue that it allows the possibility for midwives to trump hospital rules and practice inside hospital walls. They say the law essentially says the state has to allow a person's chosen personal health-care provider to carry out procedures.

Others said the benefits of a full medical staff are invaluable when giving birth. "Even the lowest-risk mom can have a serious complication," said Kathy Lambdin, nurse manager of obstetrics and pediatrics at Southeast Missouri Hospital. "If you're not sitting here prepared all the time for anything that walks in the door, how can you hope for the best outcome?"

Lambdin said each labor room has a camera so physicians can constantly monitor a mother's progress.

In hospitals the nurse-to-patient ratio tends to be 1-to-2 with low-risk mothers, but during active labor the nurse and mother work one-on-one in a hospital just as in a home birth.

New mothers at Saint Francis Medical Center are in the company of a nurse for about an hour after birth while he or she cleans the baby and the room and checks the mother's vitals, said Jack Malizzi, director of maternal and child health services at Saint Francis.

During the recovery phase, the nurse is in and out of the room providing support to the new mother for "a bare minimum of once every 10 minutes," Malizzi said.

Amanda Hicks of Poplar Bluff, Mo., considered home birth with her first child but decided the hospital would be better. However, she decided to give birth to her second child at home.

"It's really hard to get any rest in a hospital," she said. "I just wanted to be able to rest in peace. I wanted to not have to worry about someone coming in and taking my baby away from me."

She said she didn't have a horrible experience giving birth in the hospital, but at home the experience was more intimate.

Hicks said she had a low-risk pregnancy and was not worried about complications.

But an easy pregnancy does not always mean an easy delivery. "I had a perfect pregnancy and had I not been in the hospital, my first child would have died due to complications," said Dana Hukel, a mother of two and marketing and public relations manager for Saint Francis, where she delivered both her children.


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