REPORT OF COMMITTEE ON MATERNAL AND PERINATAL HEALTH
CM-MPH Report 6-A-06
Subject: Direct-Entry Midwives' Scope of Practice
Presented by: Janet Realini, MD, MPH, Chair
Referred to: Reference Committee on Public Health
In light of the 2003 revision of Texas Midwifery Board rules and changes made as a result of the 2005 Midwifery Board sunset review, the TMA Committee on Maternal and Perinatal Health harbors strong concerns about direct-entry midwives' expanding scope of practice in Texas.
The Texas Midwifery Act defines direct-entry midwifery as "the practice of providing the necessary supervision, care, and advice to a woman during normal pregnancy, labor, and the postpartum period." It directs the Midwifery Board to adopt rules "prescribing the standards for the practice of midwifery in Texas, including standards for the delineation of findings that preclude a woman or newborn from being classified as having a normal pregnancy, labor, delivery, postpartum period, or newborn period."
The board's current rules fail to meet statutory requirements, as they do not contain the specified delineation of findings but rather a list of diagnoses and a requirement that each direct-entry midwife develop and follow her own protocols. Each midwife is to define and recognize by signs or symptoms situations that require a physician's care - i.e., to make diagnoses.
Direct-entry midwives' education is inadequate to ensure the safety of mothers and newborns under these circumstances. In Texas, one may practice midwifery after passing high school, a correspondence course, and an exam. The Midwives Alliance of North America (MANA) Core Competencies for Basic Midwifery Practice - in accordance with Texas direct-entry midwives practice - list the use of "intuition" as a process of assessment and response on the same plane as clinical observation.
Many Texas physicians encounter cases in which a direct-entry midwife's failure to recognize a developing problem leads to an emergency situation. In case of emergency, the rules instruct midwives to call 911 or drop off their client at the emergency room. Too often, physicians must care for a dropped-off ER patient in desperate circumstances with little clinical history available. Moreover, ER drop-offs are not recorded as births involving a direct-entry midwife because a physician performs the actual delivery and signs the birth certificate.
Direct-entry midwives' protocols are subject to review only if a complaint against the midwife arises. The rules specify only that the protocols be based on any textbook or reference the Midwifery Board has approved for a direct-entry midwifery educational program. Thus without substantive board action, such an educational program can adopt any reference, setting new standards for direct-entry midwifery care in Texas. Another concern is that MANA includes family planning and well-woman care in the midwifery scope of practice; in Texas these areas are outside the statutory scope of direct-entry midwife practice.
Recommendation : That the Texas Medical Association (1) work for Texas midwifery rules that specify protocols and standards to be used by practicing direct-entry midwives, including clear standards for the delineation of findings that preclude a woman's or newborn's condition as being classified as normal; (2) push for all direct-entry midwife-assisted pregnancies that are either transferred/referred for emergency care or have adverse outcomes (e.g., maternal or fetal death, stillbirth, postpartum hemorrhage requiring transfusion, shoulder dystocia, maternal or fetal seizure, or any maternal complication requiring hospitalization) be reported by the midwife to a midwifery advisory body and the case reviewed by a committee that includes at least one physician; (3) support legislation that requires formal informed consent from clients that clarifies the distinction between direct-entry midwives and certified nurse midwives; and (4) oppose Medicaid reimbursement for direct-entry midwives.
TMA House of Delegates: TexMed 2006