2016 Legislative Update

January 26th, was the first committee hearing for the sunset of the Direct-Entry Midwives  (DEM) Practice Act.

A little explanation: periodically (every 5-10 years), our practice act “sunsets.” What this means is that, without reauthorization, we will cease to have regulated direct-entry midwifery in Colorado. We must go to the legislature during this time and introduce a bill to continue our practice act for another period of time (this year the recommendation is for a 7 year reauthorization). During the sunset process, the statute is opened up and changes to our practice act can be made. This year, we are hoping to add the suturing of 1st and 2nd degree lacerations to our scope of practice.

Our first hearing was held in the House of Representatives, in the Health, Insurance, and Environment committee, which is made up of 13 members. Testimony was given by both proponents and opponents of our proposed bill, along with that of the “sunset analyst” from the Department of Regulatory Agencies (DORA), who conducted a lengthy assessment of our profession and DORA’s recommendations for the next period.

DORA’s sunset analyst was the first to offer testimony. He explained the program to the committee and said that DORA recommends continuation of the Direct-Entry Midwives Practice Act for 7 years, with the inclusion of suturing for 1st and 2nd degree lacerations. He answered many questions from the committee.

Those opposed to our practice act testified directly after DORA. These opponents included a home birth Certified Nurse Midwife, a doula and nursing student, a panel of four nursing students, and members of the group the Center for Science in Medicine, which has historically opposed all “alternative” modalities, such as acupuncturists, naturopaths, and chiropractors.

Next was an economist (who is also the lobbyist for Colorado ACOG) who explained the history of how DEMs in Colorado have interacted with the malpractice insurance requirements for providers in our state. His testimony was neutral, and perhaps even more notable is the lack of opposition by ACOG.

Up next were the supporters.

Jan Lapetino, RM, CPM testified on behalf of the Colorado Midwives Association, and gave a history of the program, and explanation of our scope of practice, and made our desire for valid and accurate data reporting through a robust and rigorous method clear.

Next was Courtney Everson, PhD, who is the Dean of Graduate Studies at Midwives College of Utah and Director of Research Education for Midwives Alliance of North America. Dr. Everson explained the limitations of the data pertaining to home birth, particularly that collected by DORA and offered clarity as to current research on home birth safety. As well, she offered insight into the nature and accreditation of the CPM credential and educational process.

Next was Karen Robinson, RM, CPM, and former president of the CMA, now a licensed-practical nurse. Ms. Robinson explained the rigor of her training as a midwife, and how it did develop excellent critical thinking skills in rebuttal to previous testimony.

Next was a pediatrician in Centennial who cares for many Denver-area home born babies, and supports continuation of our program.

The President of the Colorado chapter of the American College of Nurse Midwives testified that her group is neutral on our bill.

The committee chair then opened up testimony to observers, and Larry Sarner, a long-time opponent, expressed his displeasure of our program and recommended deregulation.

At some point, two staff members from DORA returned to the stand to offer regulatory clarification to the committee.

The committee declined to vote on the bill, so an “action only” (meaning no testimony will be heard) committee will be rescheduled for a vote of whether or not to continue forward with our bill to continue the practice of direct entry midwifery in Colorado.

It goes without saying that we will need a lot of support during this legislative season. Once we have a bill number, we will be urging everyone to contact their state representatives (and then senators once the bill is introduced there). The deregulation of our program surely means home birth will cease to become an option for many women. Please stay tuned for how you can help.

Legislative Update

All regulatory professions are reviewed periodically by the legislature. The Direct-Entry Midwives Practice Act will be reviewed by the Colorado state legislature in 2016. The Department of Regulatory Agencies (DORA) Office of Policy, Research and Regulatory Reform presents a report to the legislature summarizing the history of the program including previous sunset review recommendations and changes to the law. Recommendations for the 2016 review are also made. This report will be written this summer and presented to the legislature in the fall. All interested parties are interviewed for this report.

Registered Midwives from many parts of the state met on Saturday, February 28th to discuss the upcoming sunset review of our law in 2016. The meeting was held to see what midwives want addressed during the review of our program. A list of our top priorities was determined from contacting all of the Registered Midwives in Colorado. The CMA has submitted this list to the policy analyst.

As the end of 2015 approaches, we will begin preparing for the legislative session with the help of a lobbyist. As the organization that pushed for legalization of direct-entry midwives 23 years ago and lobbied to keep the statute updated, the CMA will need the help of all supporters of direct-entry midwives during the next legislative session. Please consider a monetary donation by clicking on our Donate link.

Homebirth Safety in Colorado

Article 12-37-105(12) of the Colorado Revised Statutes requires Colorado Registered Midwives to report, at the time of renewal, the following information:

• The number of women to whom care was provided
• The number of deliveries performed
• The Apgar scores of delivered infants
• The number of prenatal transfers
• The number of transfers during labor, delivery and immediately following birth
• Any perinatal deaths (and beginning in 2011, the cause of death and a brief description of the circumstances)

The Colorado Department of Regulatory Agencies (DORA) Office of Direct-Entry Midwifery Registration collects this information via a survey administered each year to midwives seeking renewal. Through 2005, Midwives Registration reported 3 or fewer perinatal deaths associated with homebirth per year. In 2006, the survey reported 5 perinatal deaths; in 2007 it reported 5; in 2008 it reported 7; and in 2009 it reported 9. Over the last 6 years, Colorado has averaged between 40 and 60 Direct-Entry Midwives attending between 500 and 700 homebirths per year.

Much about the numbers collected by DORA over the years is unreliable. The surveys did not ask when in the pregnancy, birth or postpartum the demise took place. The term “perinatal” was not defined. The survey didn’t ask where the actual birth took place, who was managing the birth, or the reason for the demise. Because the information collected by DORA has never been refined to be used as statistical data, statistical inferences cannot be made from it.

Indeed, the Midwives Sunset Review written in 2000 recommended the Colorado General Assembly should eliminate the reporting requirements contained in §12-37-105(12), C.R.S. That review noted “the data collected by the program on renewal notices has been found to be inaccurate, and not useful in analyzing the program” and concluded, “the usefulness of the information is questionable.”

For the 2009 renewal period, Colorado Registered Midwives gave care to 936 women and attended 637 homebirths. They reported 9 perinatal demises for that year. The Colorado Midwives Association collected brief stories about the situations surrounding the demises and they are summarized below:

Premature Births:
Two babies were born premature; one stillborn a week after transfer of care to a physician due to maternal hypertension, and the other died at 24 weeks in the hospital after preterm labor.

Serious Anomaly Deaths at Term:
Three babies had serious anomalies incompatible with life. One died in-utero at 32 weeks and was stillborn at the hospital. Two were born in hospital weeks after transfer of care following discovery of the anomalies during routine ultrasound.

Other Deaths at Term:
Three babies developed nonreassuring heart tones during labor and all were transferred to hospital. Two died before birth; pathology noted an infection in the placenta of one of those babies. One died within hours after birth with an enlarged heart noted on the autopsy.

The final baby was born precipitously at home in a rural part of the state before the midwife arrived, although she was in contact with the parents during the birth. The baby wasn’t doing well, an ambulance was called and arrived but the baby could not be resuscitated and the parents requested no autopsy be performed.

In summary, setting aside the babies that had malformations incompatible with life or were born prematurely (since Colorado statute rules out premature babies for home birth) the non-malformation deaths at term comprised:

  • One stillbirth with infection present but no autopsy was done.
  • One stillbirth with no identified cause and autopsy refused.
  • One neonatal death where autopsy revealed an enlarged heart.
  • One neonatal death after precipitous birth, with no identified cause but no autopsy.

Based on the information provided, these data suggest that planning a home birth can be ruled out as a causative factor in the death in all but one stillbirth during labor, although even with this one it is not clear whether intervention such as a Cesarean section would have saved the baby, a fact which the refused autopsy may or may not have revealed. The baby born with an infection in the placenta did not receive intervention that changed the outcome even though born in hospital. The baby with the enlarged heart was also born in hospital and this apparent cause of death was not able to be treated there. The neonatal death without explanation (also with autopsy refused) was precipitous and occurred in a rural area; this baby would have likely been born out of hospital, and suffered the same fate even if a hospital birth had been planned.

Based on numerous studies already published comparing home and hospital births, it’s clear that two deaths in 600 or 700 births are not outside expected outcomes for planned homebirth of healthy low-risk women and babies attended by trained direct-entry midwives.

The mission of the Colorado Midwives Association is to support and promote the option of homebirth for childbearing families in the state of Colorado. The Colorado Midwives Association declares and affirms that homebirth continues to be a safe and viable choice for women with healthy, low-risk pregnancies when attended by a Colorado Registered Midwife.