My anticipated state of practice is California. We have some decent laws and have come very far, but still have a long way to go to fight for women’s rights to autonomous birth.
Sept. 9th 1850 – California entered into the union and midwifery was unregulated and lawful and only holistically trained midwives existed.
1917 – Midwifery became an independent profession with the California Medical Practices Act under amendment AB 1375. Holistic midwives were names “traditional non-nurse midwives”. 1,2 Category and license program developed under the California Board of Medical Examiners (now called Medical Board of California). The exception was a “grandmother clause”4 stating that actively practicing midwives had 180 days to apply and provide qualifications and satisfactory documentation that showed skill level. With this, they also had to provide 2 letters of good will recommendations by 2 professionals. One reference had to be a doctor and the other from her religious leader (priest, minister or rabbi). 217 midwives were licensed under AB 1375 with only 3 being revoked. Article 24 in AB 1375 was passed before women had the right to vote with a patriarchal provision determining the difference between “man’s tools” (drugs, sugary, etc.) and “girls tools” (non-allopathic management of childbirth) with the board being able to revoke licenses if midwives were caught using “men’s tools” i.e. anything medical.
1949 – The year Midwifery almost died. SB 966 really put midwifery on the block 5,6,7,8 . This bill abruptly dismantled midwifery with no prior notice of action. It repealed ALL practice abilities including non-allopathic treatment 9. The government stated that “midwifery was almost a dead class”. The norm became “childbirth is dangerous” and women were delivered by surgical intervention, prophylactic interventions, twilight sleep and forced obstetric management. This is the year that recommendations started of childbirth required to be Doctor attended. In reality, midwives threated Doctor’s economic status. The sneakiest part of this whole thing, the repeal came only in the final publication of the bill where it just simply didn’t include provisions for midwifery practice therefore outlawing it. Sadly, the possible proposed end to midwifery may have in fact stemmed from the fact that many holistic midwives were of Japanese descent3 and there were hostile views towards them at this time. Another factor, was the doctors coming back from war and they needed jobs and in the true male dominated fashion, shoved women out of these professions and back into their homes. This included shoving midwives out of practice due to the male doctors being more entitled to the caregiving positions, which included “delivering” babies.
1974 – Finally, after 25 years, a Nurse Midwife law was passed 10. They were deemed “physician extenders” and used to create cost effective pregnancy care to low income families. Physician supervision was required but it wasn’t legally required for physician to hire Nurse Midwives or allow them in their practice. Another hurdle was malpractice insurance refused to cover doctors that supervised nurse midwife that did any care other than in the hospital. This was also to prevent economic competition. Ah, there’s a pattern here.
1977- AB 1896 finally declared midwifery an independent discipline NOT controlled by the medical profession. New licensure was brought in September 8th 1977. There was still a long road ahead though. From 19770-1992, there was endless trying for 6 new bills to be passed to make midwifery more available and less governed by the state with no avail. You can thank the Obstetric Professionals for their vast opposition12 and fight back against the proposed bills.
1990- Senator Lucy Kella was a huge supporter of women’s rights and fought for the 6 bills mentioned above to be passed. In 1993 we finally have the introduction of SB 350 Licensed Midwife Practice Act13. This bill stated that licensed midwives were equivalent but not equal to nurse midwives. Since no physician supervision was required, it created an immense standoff between midwives and standard medicine since there was no control of these midwives by the medical profession.
August 11th 1994, after spending 50 years of arguing over aspects of “physician supervision” and majorly ignoring all other important aspect of midwifery, a midwifery committee was implemented. Its task was to “clean up” legislation and to get the supervisory clauses taken out. This resulted in requirements of each LM (licensed midwife) to submit a “written supervisory agreement” with an OB. NAFTA (North American Free Trade Agreement) deemed physician supervision was in failed system that created “unnecessary boundaries of the trade” and that licensing requirements must “not constitute a disguised restriction of the provision of services…. Requirements should be based on competence”.
1999- OAL (Office of Administrative Law) confirmed supervision of midwives dysfunctional and unenforceable. LMPA (Licensed Midwives Practice Act) cannot be used to make practice of midwifery illegal14.
2000- LMPA was amended… again. SB 147915, reduced some legal burdens by stating that each planned home birth, client and midwife were to identify arrangements for referral and/or transfer specific to each individual client. A big win was including a “legislative intent” section statin childbirth was a “normal aspect of biology and NOT a medical disease”.
2002 – SB 1950 Standard of Community-Based Practice of Midwifery. This bill required the medical board to abide by midwifery standards when making judgments on merits of complaints and not an obstetric consult. Now we’re getting somewhere.
2006- SB 1638 was signed into law including LMAR do a midwifery advisement council and licensed annual midwives report to determine the safety, effectivity, outcomes, transfer and cesarean stats. This also required 2-way communication between midwife and physician boards. The midwifery board was to be made of 50% midwifes and 50% consumers interested in midwifery. The outcome was a 6-person counsel in which 3 seats were midwives and 2 seats were taken by ACOG certified OB’s. Not exactly what was in mind when the word “consumer” was written into the bill but they found a loophole and used it. Finally, in 2012, The board agreed to replace 1 of the ACOG Certified OB’s with an actual consumer that had used the services of an LM (Licensed Midwife). OSHOD16 was created and each midwife was required to report outcomes.
2014 brought the requirements for functional communication/relationship between midwives and physicians. AB 1418, SB 1479 & SB 1950 17. Prohibition was over and freedom from physician supervision became a reality! AB 130818 made the repeal final however, massive restrictions on scope of practice for the midwives was now signed into law. This provision shifted a lot of low risk qualifying women into “high risk” positions and in a transfer to physician category. Criminal penalties were also now implemented for failure to comply with transfer or referral laws. It was basically a sneaky “land grab” at best. Midwives now had strict restrictions of no postdates pregnancies, no multiples, cephalic presentation (head down), no preexisting maternal diseased likely to affect pregnancy, and more. There’s also items in the bill that state a physician can risk them out if they decide that the patient is “high risk”. The other incredibly sneaky addition, or should I say non-inclusion, was once again, the writers of the bill simple didn’t include SCCLM in the final revision. This revoked the requirement of the medical board to use midwifery standards when judging the merits of a complaint. The bill was signed on October 9th 2013. This was deemed “the single most detrimental aspect of AB 1308”.
2015 – Two amendments were signed into LMPA. a.) SB 408 – legal category of “midwife’s assistant” 19 b.) SB 407 – can be compensated for providing care to Medi- Cal recipients. 20
2017 – AB 1612 passed and finally releases CNM’s (Certified Nurse- Midwives) from physician supervision with the allowance to practice independently 21. AB 1368 passed which was the final repeal of supervision.
2018 – CALM’s (California’s Association of Midwives) Bill 23: Access to Midwifery Act of 2018 failed. The good thing, though, is that Bate’s Bill (SB 475) that would severely limit access to out of hospital care also failed which deemed “The patient or client has not had prior uterine or abdominal surgery, including, but not limited to, myomectomy, hysterotomy, or prior caesarian section.” 22 among other damaging revisions to the current scope of practice.
The current status of midwifery in my state, is that it is legal under the LM licensure with many restrictions on scope of practice including but not limited to no breech presentation or multiples. There are also frequent bills threatened to take away rights of practice as well as bills that are not approved for expansion of scope of practice with a bill actually just introduced on the 13th of June 2018 with even more paternalistic restrictions proposed 24.
In conclusion, as you can see. The fear surrounding Midwifery and birthing at home is not based on danger. ( I will have stats in studies on the next blog). There is a long history, extending way back to the Spanish Inquisition world wide (also in a blog to come), of immense pressure against midwifery and woman healers and it’s mostly based on eliminating economic competition and men monopolizing an aspect of healthcare that may not be an area they should be in. Over time we have made something that wholly feminine and made it intrusive and masculine. We try to dominate, and calculate and put birth on a timeline when it cannot be. Midwifery allows the body to do what it’s going to do where standard obstetric care puts in on a timeline and a linear pattern.