Homebirth in Connecticut, Part II

Last year, the Connecticut Superior Court considered an administrative appeal by two midwives who were sanctioned by the state’s Medical Examining Board (the agency that licenses physicians) for the alleged practice of medicine without a license.  I would love to summarize the facts of the case here, but it’s a long story with lots of technical details, and I don’t think I can do the case justice by simplifying it down to a paragraph.  Suffice to say that the Board told the two midwives, who were Certified Professional Midwives licensed not by the State of Connecticut but by NARM, a private organization, that they overstepped their boundaries as midwives by providing what constituted medical advice to a woman during the course of her prenatal care, as well as during labor.  On appeal, Judge Henry Cohn found that the Board had, in fact, overstepped its own authority in going too far with the cease and desist order.  He found that the CPMs could assess the woman’s condition and determine whether to seek medical help, for example, just as any non-physician can assess that something is clearly wrong and that it is necessary to go to the hospital.  However, the Court did not disturb the Board’s findings that the CPMs acted illegally by providing advice contrary to that of the woman’s OB/GYN (she had received parallel care during her pregnancy).

In case you’re wondering, Mom and Baby are alive and well and, from what I am told, did not seek any action against the CPMs, or see any reason to.  However, it is reported that a doctor who was disturbed by the woman’s attempted homebirth, which ended in a hospital transfer, reported the CPMs to the State, beginning this litigation — back in 2000.  The Board’s cease and desist order was not issued until 2008, and it took three more years for this matter to be heard by the Superior Court.  Because the decision was a partial win, partial lose for both the State and the CPMs, the parties have filed cross-appeals with the Connecticut Appellate Court, where the case awaits oral argument.

As mentioned above, the Medical Examining Board, the agency that licenses physicians, heard the case and then sanctioned the two CPMs for the unauthorized practice of medicine.  It’s what would happen if I held myself out to the public as a licensed physician, when in fact I am just a lay person, and then went about treating people under the guise that I am a doctor.

But Certified Professional Midwives don’t practice medicine.  They practice midwifery.

Midwifery! Read all about it at Citizens for Midwifery.

The State of Connecticut does not license CPMs, but it does define and regulate the practice of nurse-midwifery. In Connecticut, you can be licensed as a Certified Nurse-Midwife if you are eligible for registered nurse licensure by the State, are certified by the American College of Nurse-Midwives, and have completed additional hours in pharmacology.

What exactly constitutes the practice of medicine?  Section 20-9 of the Connecticut General Statutes defines the practice of medicine by describing what one may NOT do in the absence of a physician’s license:  “No person shall, for compensation, gain or reward, received or expected, diagnose, treat, operate for or prescribe for any injury, deformity, ailment or disease, actual or imaginary, of another person, nor practice surgery, until he has obtained such a license as provided in section 20-10, and then only in the kind or branch of practice stated in such license.” (Emphasis added.)  This statute also includes a list of circumstances that are expressly not considered to be the unauthorized practice of medicine.  Nurse-midwifery is included in the list, as is the rendering of emergency medical assistance.

Funny, I didn’t realize that being in labor constituted an “injury, deformity, ailment or disease.”

Which brings me back to exactly what CPMs do for a living:  Just because the State doesn’t license CPMs doesn’t make what they do illegal, and it certainly does not mean that any midwife who is not a nurse-midwife is, by default, practicing medicine without a license.  The State neither prohibits nor promotes the practice of attending homebirths.  There are no built-in criminal penalties in Connecticut for attending a homebirth, nor is the act of giving birth at home itself illegal.  If such prohibitions did exist, then a woman giving birth at home by herself, or a husband or aunt who stays with the woman during her homebirth to provide emotional support, could be hauled away to jail.  So it is important to keep the court decision in the proper context:  the crux of Albini et al. v. Medical Examining Board is whether the State overstepped its authority in telling the CPMs that they could not advise their client on matters concerning her pregnancy and the birth of her baby.  

In Albini, the CPMs had told the mother that she could have a homebirth after an OB had told her not to, because of a transverse lie.  I don’t know if we are missing facts here — perhaps the CPMs found a way to reposition the baby prior to attempting a homebirth, perhaps not — but this occurrence set the stage for the State to tell the story of two unlicensed midwives who recklessly told a pregnant woman to ignore her doctor’s advice at the peril of herself and her child, rather than the story of two trained professionals who independently assessed a woman’s pregnancy and issued a separate opinion that a home delivery was feasible.  Consider that, if the woman had instead sought a second opinion from another licensed OB/GYN, and that second doctor rather than a CPM had provided the contrary advice, there would be no action against Doctor #2 for the unauthorized practice of medicine.

Regardless of whose story you find more convincing, should the State be in the business of shutting down homebirth midwives?  The purpose of licensing physicans to practice medicine is to protect consumers, including consumers who are pregnant women, who may choose to obtain care from an OB/GYN or a CNM, but may instead choose to deliver at home with a CPM, or some other individual — or no one at all.  But in the U.S., the overwhelming majority of women receive their prenatal care from an OB/GYN practice and deliver their babies in a hospital; in 2008, only 0.67% of recorded births in the U.S. were the result of a planned homebirth.

Will birth outcomes improve in this state by contorting the legal definition of the practice of medicine to include the oversight of the normal birth process, just because the woman chooses to remain at home during her labor?  I think not.  Let’s hope that the Medical Examining Board drops the witch-hunt, and instead, starts taking action that will actually improve the care provided to pregnant and laboring women — perhaps by recognizing the private CPM certification and taking reasonable measures to regulate the practice.

14 thoughts on “Homebirth in Connecticut, Part II

  1. Melanie, this topic is SO IMPORTANT and I do appreciate your posts about it. I have very strong feelings about this having had three unassisted homebirths myself, which I realize this is an even more radical choice than midwife assisted homebirths. With my first pregnancy I went the OB route, only to find myself, my pregnancy (and my intuition) feeling sabotaged and even violated. In all my research and experience it is VERY, VERY clear that the regular, traditional route of OB care is steeped in fear and operates from that place of fear throughout the whole pregnancy and birth process. Midwifery is so important because it is a gentle guide that helps a woman find her own voice and intuition, as well as the voice of her baby’s. Homebirth is THE ONLY way I could have gone ~ it’s the only way I felt safe and comfortable enough to open up to my body’s wisdom. And that’s REALLY what birth is all about ~ surrendering to the wisdom of our body to do what is natural. My homebirths were beautiful, empowering, peak experiences…and that’s how birth should be for EVERY woman. Period.

    1. Thanks Kate, I feel the same way. I think a lot of people don’t understand the intense need for privacy and dignity that some of us have during labor. I toured the hospital during my pregnancy and I just knew it wouldn’t work for me.

  2. While I have readily admitted that homebirth would never be an option for me, I am really grateful to you, Melanie, for an insightful, honest and educational post. You rock, girl.

  3. Thank you, Melanie, for helping alert CT women to the fact that our state medical board is infringing on our rights to choose the manner in which we give birth. By using the bogus “practicing medicine without a license” accusation to intimidate qualified, credentialed midwives who provide unparalleled care and are much-loved by their clientele, the medical board is harming the very women it is charged with protecting. Their energy would be a lot better spent on improving the sorry state of obstetric care, since that’s where 99% of women will be at risk of mismanagement of their pregnancies.

    I have had two healthy babies in my home (one with a CNM and one with a CPM, both of whom were excellent care-givers). I feel very lucky to have been able to give birth at home and wish all women knew how wonderfully home birth midwives care for women.

    1. Thanks! I agree that the energy (time, tax dollars, etc.) would be better spent improving birth outcomes for all women, including improving maternity care and hospital practices in general. I would love to see better education and training for OB/GYNs, CNM’s, and other hospital staff. For what it’s worth, because I know this will probably come up again, I did have a good experience with the L&D nurses at Hartford Hospital last spring when I was admitted for a stomach flu (I was something like 32 week along at the time, so they put me in L&D). I think there are some awesome birth professionals in the practice, good and bad doctors, good and bad midwives, etc., so I didn’t mean to make it sound like I was totally trashing the hospitals and the medical world in my original post. But yes, the key decisionmakers and policymakers need to be better educated and start taking actions that help women and families by focusing on improving birth outcomes, not by taking arbitrary and targeted action against CPMs, which does nothing except limit our already scarce options.

  4. [i] Just because the State doesn’t license CPMs doesn’t make what they do illegal, and it certainly does not mean that any midwife who is not a nurse-midwife is, by default, practicing medicine without a license.[/i]

    Actually, that is precisely what CPMs are doing by attending home births, which is a dangerous and reckless practice that brings with it a threefold increase in neonatal deaths (and that’s WITH a licensed midwife in attendance, let alone CPM- or unassisted-homebirth cases). Birth is natural, yet — but what many NCB and homebirth advocates fail to realise is that NATURAL IS NOT NECESSARILY SAFE. Cancer is natural. Tuberculosis is natural — and yet, these things are dangerous and may lead to rather unpleasant outcomes. Before the advent of modern medicine and hospitals, more women died in childbirth — a normal, natural process — than by any other means. Women in other countries, especially third-world countries, would love to have the safety and interventions of a L&D unit. If a woman chooses to have her baby at home, that is her choice, yes. But she is putting her baby at a much higher risk of being injured or killed, and [b]that[/b] is an unforgivable, negligent and disgusting crime — and a CPM who thinks she is as qualified and educated as an obstetrician (and believes that homebirth is safe) is a criminal as well for practicing.

    CPMs are not licensed because the Medical Licensing Board recognizes that they are NOT medical professionals, and women’s lives are at risk by birthing with them. Women who choose a “natural” (as they put it) child birth should look to delivering with a licensed CNM-type midwife and doula in an OB-supervised hospital, or at the very least, a birth center attached to a hospital with an L&D unit, a NICU, and the lifesaving equipment and professionals that she and her baby might need.

    1. This is a completely false argument. First of all, comparing a natural process (childbirth) to diseases (cancer and tuberculosis) is not sound logic. Second of all, CPMs are often more qualified and educated for attending NORMAL, UNCOMPLICATED births than obstetricians, who are trained in surgery. If an OB is just out of med school, how is he or she any more qualified to attend a birth than a CPM who has attended hundreds of births? Thirdly, there was a medical study that concluded “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.” http://www.bmj.com/content/330/7505/1416

      Finally, yes, the advent of medicine saved lives, but bringing birth into the hospital caused MORE deaths by infection than home births of the era. And women who have births in the hospital in the US have about a 30% chance of having a (often uncessary) Cesarean section, which causes more complications because it is major surgery.

      If you are going to make an argument, please be informed about your facts instead of just accusing CPMs of being criminals.

      1. “If an OB is just out of med school, how is he or she any more qualified to attend a birth than a CPM who has attended hundreds of births?”

        -This is what we call “medical school.” While I agree that experience accounts for being able to assess risk when caring for patients, I would take a brand-new physician over Ina May Gaskin herself. Believe it or not, OBs actually learn something in medical school.

        “Thirdly, there was a medical study that concluded “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.””

        -Yes. With CERTIFIED midwives.CNMs. A CPM is very different, Acting as a health care provider when you have not been accredited and licensed as one is a criminal act, as you are putting anybody you attempt to “treat” in danger.

      2. All – we at CTWorkingMoms support an open discussion about issues like this but only if done so in a respectful manner. There are many sides to this issue so please refrain from demeaning points of view that don’t align with your beliefs. Thanks in advance. (This goes out to all commentors)

      3. In most fields (medicine, teaching, psychology, among others), quality of care or service provided is actually most often not influenced by length of experience, but by initial training and skill levels. This is often hard for people to accept because it flies in the face of our “common sense” (we think that the more we do something the objectively “better” we get at it, and that this naturally will apply to work settings), but research demonstrates that this is not the case, and in fact a person’s initial performance in their work typically sets the tone for their continued performance (a poor teacher will remain a poor teacher, a good teacher a good one, etc., regardless of work duration). A well trained doctor just out of med school is very likely more competent to assist in a birth as compared to someone without any medical training or suitable education, regardless of the discrepancy in their length of experience. It is not intuitive, but that is why we have research; our ‘gut feeling’ is not a good source of accurate information.

        Regarding comparing childbirth to a disease, it doesn’t seem the intention is to cast childbirth as a bad thing, but rather to highlight that it is in fact /dangerous/. It causes untold changes to the body and can directly lead to many diseases and dangerous medical conditions. While it in and of itself is not a disease, to make the argument that it is not worthy of medical attention or merits no comparison to a disease is silly. If a woman were to have a condition that caused fatigue, high blood pressure, weight gain/loss, diabetes, mood changes, nausea, pain, and risk of death or permanent disability, and we left out that she was pregnant, that would certainly raise alarm bells and necessitate careful monitoring by trained medical professionals. Acknowledging that there are real dangers along with pregnancy should not negate the idea that pregnancy is also wonderful, positive experience that results in bringing a new and welcome life into a family, and it seems in this discussion as though these are seen as mutually incompatible. Why not have open and realistic eyes and take reasonable precautions for the safety of both mother and child, while working to improve state of medical care around pregnancy, than deny possible risks in order to pursue a fantasy of idealized pregnancy and birth which includes engaging in a behavior that, while ideally is low risk, is still certainly statistically speaking more dangerous than a hospital birth, not only to children but to mothers (who often are left out of the discussion, with the emphasis only on risk to the child).

        On the note of C-sections, vaginal birth isn’t really something to be idolized either:

        And most women recover from a c-section and are thankful that there was a procedure available that obviated the need to undertake a potentially high risk birth. (Note that this is not a defense of the high c-section rate; certainly this can and should be lowered, but is the way to do this avoiding medical care? Talk about throwing out the baby with the bathwater!). The process of birth is messy and dangerous and can have long-term health consequences. A homebirth isn’t a magical solution to those problems, it’s an act based on exaggerated fears of the medical system and societal pressure on women to have perfect birth experiences while fearing that they might do something that will put their child at risk. That is not a recipe for an informed pregnancy and birth.

      4. Passerby, thanks for leaving a well thought out and respectful comment. Here are my thoughts.

        I think a lot of people who question the safety homebirth make the assumption that being in a hospital is just, in and of itself, safer … just because. But you’ll notice that no one can ever seem to find any credible and non-biased studies supporting that hospital births are inherently safer than out-of-hospital births for low-risk women … because there are none. Of course, that doesn’t mean that such studies should not be commissioned, and we should continue to look at this issue, as homebirth proponents have certainly done. But the bias is clear, for example, in statements such as yours that midwives have no education or training … that is simply not the case. What IS true is that midwives and doctors are trained differently, and I do value and respect the honest and courteous debate over which approach is “better” in a given situation. For my part, I do believe that the evidence supports a high touch, low tech approach to birthing as safer than the high-intervention medical model of birth, and from what I have researched, the best way to avoid unnecessary interventions is to give birth at home.

        We must also question the dangers of hospital birth, which I believe are primarily caused by the doctors and hospital practices themselves. For example, you may believe that an epidural for pain relief is safe, because so many women get them, so they must be ok. You may be surprised to learn that an epidural carries with it a risk of paralysis! Yet I would never tell a woman who requests an epidural that she was wrong for putting herself and her baby in harm’s way because of this … the risk is relatively rare … just like the risk of a complication for an otherwise healthy mother/baby during a homebirth. Another point on the dangers of hospital birth is that doctors seem to have a proclivity toward intervening, just because birth is not following what their med school textbooks said it should look like, and these unnecessary interventions cause so many of the problems that make people say “oh it’s a good thing I was in the hospital because XYZ happened.” For example, so many doctors want to induce labor when week 40 of the pregnancy hits (or earlier!), because the book tells them the baby “should” be out when research suggests that it is safer for the baby to wait until labor begins spontaneously. I don’t know the reasons why OB/GYNs are trained this way, but they are. Induced labors are more painful and more dangerous because of the increased risk that the baby is simply not ready to be born (e.g., breathe on its own). So I question the assumption that hospitals are the safest place to be to give birth.

        I do agree with you, generally, that birth is not inherently safe. Birth is as safe as life gets, so they say. Almost nothing we do is entirely safe — taking aspirin, driving a car, getting an epidural — but we do these things anyway. Again, if giving birth in a hospital was proven to be statistically significant in improving health and safety for a healthy woman with a low-risk pregnancy, I would certainly do it, but the evidence is just not there.

        Finally, I can tell you that my choice to have a homebirth, two actually, was not out of the desire for an unrealistically perfect birth. Actually, I knew it would be difficult, but I also believed it was the safest way to give birth for me and my baby. Sure enough, my first labor was prolonged and very painful, with a posterior baby that was literally a pain in the butt. Thankfully I was home, because in the hospital I would have been an unnecessary c-section, which I did not want. But my second birth was fast and furious and amazing — we actually called our midwife too late by accident, so I had an unplanned “unassisted” birth of sorts (our doula was at least there to help). I hope every woman who gives birth has the opportunity to have such a great experience — no matter where or with whom she chooses to have her baby.

  5. If a baby is transverse, then it is poor midwifery not to immediately risk out a client and refer her to an OB/Gyn. Homebirth midwifery is supposed to be limited to low risk pregnancies. If a baby is transverse, then she is not low risk and cannot delivery vaginally, unless the baby turns head first.

    Contrary to the nonsense that many homebirth advocates contend, breech is not a variation of normal. In fact, it is logically impossible to have a variation of normal. Variation means a deviation FROM normal.

    Once a woman is deemed high risk with any condition that is a deviation from normal in pregnancy, and continues to be cared for my a midwife who is advising her about her high risk condition, then the midwife is indeed practicing medicine.

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