NACPM Standards Provide Protection for the Midwives Model of Care™ in Wisconsin and Virginia

I. Wisconsin by Edie Wells, CPM,LM
More than 20 years ago, Wisconsin midwives attempted to pass licensing legislation, prompted by the prosecution of a midwife. The midwives experienced an uphill battle because there was no national credential for midwives and no published statistics regarding safety and outcomes. The bill required very specific practice guidelines and certification by the state midwifery organization. The story is that a deal was cut on a racquetball court that if the midwives would drop their licensing efforts, the witch hunt for direct-entry midwives would be dropped as well.

In June 2003, the midwives took up the cause of licensing again. When we first approached legislators in our most recent attempt, we were told it would be difficult to recruit a sponsor unless there were national standards of practice for Certified Professional Midwives. Luckily for us, the NACPM standards had just been approved and, along with the CPM 2000 study published in the British Medical Journal, they became the key that opened the door to success.

The NACPM standards are referenced in our legislation as follows:

440.984 Rule making. (1) The department shall promulgate rules necessary to administer this subchapter. Except as provided in subs. (2), (2m), and (3), any rules regarding the practice of midwifery shall be consistent with standards regarding the practice of midwifery established by the National Association of Certified Professional Midwives or a successor organization.

This paragraph offers midwives in Wisconsin a great deal of protection from being forced into state rules that reflect the medical model of care and it preserves the Midwives Model of Care™ in our rules of practice. We are very grateful to the team that worked so hard to develop the Standards document.

II. Virginia by Leslie Payne, CPM, LM, Chair, Advisory Board on Midwifery to the Virginia Board of Medicine
Midwives, consumers and supporters in the legislature had the amazing foresight to include an explicit reference to the NACPM Standards of Practice in the legislation to license CPMs in Virginia. Because of this reference to the Standards in the statute, this document provided a safeguard for the creation of the Rules and Regulations for Licensed Midwives. Its power derives from the fact that it is written by CPMs themselves and reflects how CPMs actually practice. In Virginia, midwifery is regulated by the Board of Medicine, whose members are not well informed about the practice of midwifery. Without this reference to the Standards in the legislation itself, the Board of Medicine would not have been required to use midwifery criteria in the development of rules. Thankfully, the licensing statute includes a provision for an Advisory Board on Midwifery to the Board of Medicine, whose role it was to develop the Rules and Regulations to govern the practice of midwifery in the Commonwealth. This Advisory Board includes three CPMs, one obstetrician or Certified Nurse Midwife, and one citizen member, all appointed by the Governor.

As I’m sure is true in most states, the staff of the regulatory agency composed the first draft of our Rules and Regulations. By the time of the first meeting of the Advisory Board in August 2005, much of the standard licensing language was already in place, composed by the Senior Policy Analyst at the Board of Medicine. The drafting of Practice Standards (Part III of our Regulations) generated the most discussion. We were advised of the importance of generating 5-6 standards that would define what Licensed Midwives would be expected to do, be responsible to do, and refrain from doing. These standards would inform any disciplinary action that might be imposed on a midwife as a result of an investigation into a midwife’s actions or practice. The Advisory Board and Staff developed the 6 statements that you can read below. As you will see, the first four are based on NACPM Standards Two and Three, as well as the “Philosophy & Principles of Practice” and the “Scope of Practice for the NACPM.” Some of the language is derived directly from the NACPM Standards. (The last two standards are based on rules that apply broadly to practitioners in Virginia.)

I believe that it was crucial for the NACPM Essential Documents to be directly referenced in the statute in their entirety. It would not have worked to simply use the language from the Standards in our Rules and Regulations, without the backing of that direct reference in the statute. I anticipate that Licensed CPMs in Virginia will be very grateful to be able to document that the care of a CPM is based on the concept of Informed Choice—something that is difficult for the medical community to understand. Our care has a very different focus from the medical model, and this is clearly defined by these Essential Documents. I breathe a sigh of relief and thanksgiving every time I read them. Many thanks to all who worked so hard to craft the language that defines what we do.

The section of the Virginia Rules and Regulations below demonstrates how language was used directly from the NACPM Essential Documents.

III. Practice Standards

18VAC85-130-120. Practitioner responsibility.
A. A practitioner shall:

1. Transfer care immediately in critical situations that are deemed to be unsafe to a client or infant and remain with the client until the transfer is complete;
2. Work collaboratively with other health professionals and refer a client or an infant to appropriate health care professionals when either needs care outside the midwife’s scope of practice or expertise; and
3. Base choices of interventions on empirical and/or research evidence that would indicate the probable benefits outweigh the risks.

B. A practitioner shall not:

1. Perform procedures or techniques that are outside the scope of his practice or for which he is not trained and individually competent;
2. Knowingly allow apprentices or subordinates to jeopardize client safety or provide client care outside of the apprentice’s or subordinate’s scope of practice or area of responsibility. Practitioners shall delegate client care only to those who are properly trained and supervised; and
3. Exploit the practitioner/client relationship for personal gain.

The Midwifery statutes are on pages 49-52 of the Chapter 9 Code of VA/Medicine which you can download at http://www.dhp.state.va.us/medicine/leg/Chapter%2029%20Medicine.doc The rules can be downloaded at http://www.dhp.state.va.us/medicine/leg/Midwives2-21-07.doc