While one profession lays claim to being the world's oldest, there's another that's just as ancient – midwifery.
And yet, if S.C. House bill 4024, introduced in April and likely to be taken up in the next legislative session, is passed, some feel that lay midwives could be on their way out in South Carolina, as has happened in other states where hospital-backed legislation has regulated them almost out of existence.
Practitioners and supporters of the profession contend that the bill, sponsored by two doctors, Reps. Kris Crawford, R-Florence, and Robert Ridgeway, D-Clarendon, not only tries to fix something that wasn't broken, but is an end-around by legislators with their own personal motives for seeing the role of midwives diminished.
They point out that Ridgeway is an obstetrician and gynecologist (OB/GYN), a doctor with a professional interest in seeing babies born in hospitals and not in homes, which is where most midwives practice.
The first bill introduced by Ridgeway and Crawford was H. 3731, which was referred on Feb. 28 to the House Medical, Military, Public and Municipal Affairs Committee, chaired by Rep. Leon Howard, D-Richland. The legislation sent shock waves through the midwifery community, with practitioners blasting it as a blatant attempt to all but eliminate the lay midwife profession in the Palmetto State.
(The Nerve reported earlier this month that Crawford, who works for a medical staffing company, owns a medical firm bearing his name, and is a partner in another medical company, didn’t report any Medicaid payments he received for treating patients on his six most recent state income-disclosure forms, though he was the main sponsor of a bill (H. 4095), introduced in May, that would accept Medicaid-expansion funds under the federal health-care law known as “Obamacare.”)
H. 3731, which didn’t move out of committee, would have required lay midwives to have both a “sponsoring obstetrician” to recommend their licensure and a “supervising obstetrician” to take responsibility for their outcomes. With doctors everywhere complaining about the skyrocketing costs of malpractice insurance, the real-world result of that bill effectively would have been that no new midwives would be licensed, according to consumer and midwifery advocate Martin Herbkersman of Columbia, whose five children all were birthed at home with a midwife.
Herbkersman is the brother of state Rep. Bill Herbkersman, R-Beaufort.
“That would basically have killed any new midwives from here forward, because no OB in town would take that liability on, especially for someone they in essence are competing with,” Martin Herbkersman told The Nerve. “It would effectively kill midwifery in South Carolina, which would be devastating for the profession and bad for consumer's freedom of choice.”
Herbkersman pointed to Georgia, which since the 1960s stopped certifying midwives who were without nurse training, making the practice of lay midwifery a misdemeanor crime and preventing their services from being covered by insurance companies.
Georgia is among 12 states, including North Carolina, Kentucky and Alabama; and the District of Columbia where direct-entry midwifery (also called a “lay midwife”) is either illegal or licensure is not available, according to the Midwives Alliance of North America.
South Carolina is among 27 states where currently it is legal to hire a lay midwife, according to a 2010 Time magazine article, though hiring a certified nurse midwife (CNM) is legal in all 50 states. Certified nurse midwifes are advanced-practice registered nurses who have received additional professional specialization in both nursing and midwifery. Lay midwives may or may not have certifications, licenses or degrees, depending on what state they practice in, though most do through national entities such as the American College of Nurse-Midwives or the Midwives Alliance of North America.
Hospitals Protecting Profits?
Susan Hodges, who runs the Georgia Friends of Midwives, says the liability issue is one doctors often trot out, though she contends that it is disingenuous.
“The doctors have made liability an issue, but that's not really the issue,” she told The Nerve. “The issue is every woman who has her birth at home with a midwife is not having it at a hospital with an obstetrician. That's a loss of money, not an insurance issue.”
Both Herbkersman and Hodges argue that it has been the longstanding policy of the American College of Obstetricians and Gynecologists (ACOG) to marginalize the midwife profession though scare tactics, pointing to the ACOG's official position on midwifery as being inherently dangerous.
“Although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth,” according to ACOG’s website.
Hodges said such claims are fear-based, do not take into consideration all available data, and are inherently biased.
“Hospitals do not want babies birthed at home out of their supervision that they don't profit from,” she said. “They refuse to look at overwhelming evidence that shows how safe home births are, and don't talk about how dangerous many hospital births are.”
“This kind of legislation is nothing more than a way to make it more difficult for their competition to operate and increase their bottom line at the expense of consumer choice, and the facts that a hospital is a more dangerous place to have a child than a home,” Hodges continued. “It's worked fine for thousands of years before there were obstetricians and hospitals to intervene and charge people.”
Ridgeway said he heard the criticisms of H. 3731, which is why H.4024 was introduced almost two months later and eliminated the supervisory role of OB's. As with the first bill, H. 4024, introduced on April 24, didn’t move out of the Medical, Military, Public and Municipal Affairs Committee this year, though it can be taken up again when the Legislature returns in January.
'Clear Conflict of Interest'
The second bill, however, kept the mandate in H. 3731 to move licensure and oversight of lay midwives from the S.C. Department of Health and Environmental Control (DHEC), where it had been for decades, to the state Department of Labor, Licensing and Regulation (LLR), placing it directly under the control of the physician-dominated Board of Medical Examiners.
Ridgeway told The Nerve that the need for the bill came solely from DHEC, which no longer wanted the responsibility of governing lay midwives.
“DHEC wanted the regulations revised concerning midwives,” he said. “DHEC realized it had no authority to impose fines on the midwives for infractions. Its only authority was to revoke or suspend someone's license.
“So if a midwife committed an infraction that was not worthy of suspension or revocation, they have no recourse.”
Ridgeway said he did not know how many cases of infractions there were or the percentage they represented of the total number of practicing midwives. Herbkersman said even the midwives themselves don't have access to the data they themselves submit to DHEC.
“I've met with midwife groups, and they've been under DHEC with no problems for a long time,” Herbkersman said. “Meanwhile, the midwives I've spoken to tell me DHEC won't give them the statistics they want and need to defend themselves. Midwives file a quarterly report, and they say DHEC hasn't given them the info they've requested.”
Ridgeway said DHEC was most concerned about eliminating areas where it oversees people so it can focus on its role as overseeing entities, and leaving individual professional licensing to LLR, which specializes in it.
“When you look at DHEC, it's basically an organization that licenses other organizations or entities like hospitals, landfills, nursing homes and the like,” he said. “They usually don't oversee people; the only people under their umbrella are licensed midwives, hearing-aid salesmen and EMS people because they are over licensing for EMS services for the state.
“LLR, in contrast, oversees professionals like pharmacists, physicians, nurses and people in the medical field. It seems proper to have the licensed midwives as a group of professionals under an entity like LLR, which is responsible for mostly professionals instead of organizations.”
The problem with the change, Herbkersman said, was that the new seven-member licensed midwife committee under LLR puts lay midwives at a voting disadvantage, as only two of the seven would be lay midwives. The rest of the committee would be comprised of a physician, two nurse midwives (who are primarily hospital nurses with an additional certification), a consumer of midwife care and a member of the Board of Medical Examiners.
“With this committee arrangement, the lay midwives are essentially a non-factor as a vote regarding their own licensing and discipline,” said Herbkersman. “Midwives have been governing themselves just fine, and now they're essentially put under the thumb of their competition. It's the classic fox-guarding-the- henhouse situation.”
Ridgeway says he sees no conflict.
“I don't think there's competition between OB's and midwives,” he said. “I've worked with midwives for a long time. I think there's room for everyone.”
For Hodges, such statements are hogwash.
“How in the world is it not competition?” she said. “Competition is exactly what it is. If you look at medicine, obstetricians and midwives are essentially competitors.”
You can sugar-coat it, but it's competition for customers,” Hodges continued. “This is a business environment. This is a case of physicians using their position as legislators to write bills that make it harder on their competition to operate.
“It's as clear a conflict of interest as they come.”
Reach Aiken at (803) 200-8809 or firstname.lastname@example.org. Follow him on Twitter @RonAiken. Follow The Nerve on Facebook and Twitter @thenervesc.