7. What Can Midwives Do?
Description
This article is from the Midwifery FAQ, by cnmpat@aol.com (Pat Sonnenstuhl) with numerous contributions by others.
7. What Can Midwives Do?
This will depend on the type of licensure and the laws and restrictions
within the local area.
CNMs can obtain hospital privileges, in some states can prescribe most
medications needed by women, and can attend birth in the home, hospital or
birth centers. They can provide family planning and women's health care
in addition to the full scope of prenatal and birthing care. How they
practice will depend upon their work setting.
Some CNMs practice in large, busy Level III hospitals. This is usually
episodic care, and they might work shifts and specific clinics, and be
able to work a limited 40 hour week. Some CNMs have a solo private
practice and others work in group practices with other CNMs and/or
physicians. Most CNMs provide total midwifery care, with a physician for
consultation and co-management as needed. CNMs can earn a consistent
income, and can also practice as an RN if she cannot work as a CNM.
Sometimes CNMs work for a family planning agency such as Planned
Parenthood or the Health Department providing family planning services
and women's health care. Some CNMs practice midwifery internationally on
special projects for the American College of Nurse Midwives. Present
projects include work in Ghana, Egypt, Uganda, Indonesia, Morocco and
Bolivia and include work with family planning agencies and the training
of training of Traditional Birth Assistants and working towards
improving the overall standard of living for women and their families.
Obtaining hospital privileges in the United States is a critical element in
a midwife's ability to practice and use the resources found within the
hospital, such as the lab, radiology and the emergency room. Hospital by-
laws can be written to either include or exclude this non-physician
provider. Some by-laws require physician supervision and sometimes their
presence at the birth. Other by-laws are more liberal. CNMs have made
many strides over the past few years, and many hospitals are receptive
to midwives. Women are requesting the care of midwives, and hospitals
choose to offer this option.
Non-physician providers in some institutions, can independently admit and
discharge their clients, however cannot vote on any committees. CNMs attend
the perinatal committee, which discusses the rules and regulation of the
particular obstetrical unit, but they are not allowed to vote on rules
which might affect them. CNMs attend these meetings, and their visible
presence makes an impression at some level to their viability.
The by-laws limit who can practice. Each candidate is carefully
screened for accuracy of licensure and educational program. Probationary
periods exist for different practitioners, and requirements for non-
physicians might differ somewhat from what is required for a physician.
Hospital administrators are looking at different models of health care,
and at countries where midwives provide most of the care.
The issue of hospital privileges affects non-CNMs, if they were to want
privileges, or even to use the services available at the hospital. The
midwife without privileges would need to go through a physician or other
provider to get an ultrasound ordered, and the results would go to the
physician, not the midwife. Many midwives do not seek hospital
privileges, but others want to be able to transition their clients into
the hospital should the need arise, and be able to continue care within
the hospital. Some DEMs also sit on various committees in their states
and are able to promote change in obstetrical care, along with the
consumers in the community.
Midwives without a formal license practice in a variety of ways and with a
variety of tools. Some use homeopathic, herbal and other non-allopathic
therapies within their practice, such as massage, accupressure and
reflexology. They assist births in the home or within a birth center.
Some midwives are considered to be practicing illegally in their state
by some authorities. It is not illegal to have a home birth, but it
might be illegal for a midwife to attend the birth without appropriate
licensure. A good example is in Washington State, where there are CNMs,
Licensed Midwives and non-licensed midwives. If the non-licensed midwife
charges for her services, this is considered illegal by state law.
Licensed midwives and CNMs can bill for their services through the
state, and be reimbursed by insurance plans. Many midwives practice
independent of any major medical community, consulting with a specific
physician if necessary that is supportive of their cause, or having the
client seek a consulting physician should problems arise.
In some situations, midwives contact whatever back-up is available, using
the hospital's on-call physician should transfer be necessary. A
hospital's reception of a midwife's transport may vary. Sometimes the
midwife and parents face a physician or nurse who disapproves of the
intended birth at home. However as midwives and out-of-hospital birthing
have become more common, the hospital staff has become more likely to
greet the transport with professional respect. Licensure or
certification provides a minimum standard to which midwives adhere. The
intention is to protect the consumer from harm by a practitioner without
adequate training, but is no guarantee of competency.
Licensure and certification also imply a peer review process to help
midwives feel accountable for their actions.
In the USA, CNMs usually work from standing protocols that they have
developed themselves. These are reviewed by their consultant physicians,
and guide care. Generally these are of a medical or allopathic
orientation, however there are CNMs who use herbs and non-allopathic
treatments within their practice. The ACOG (American College of
Obstetrics and Gynecology) has well documented and clearly presented
guidelines for practice, and most seem respectful of the diversity of
practice within the USA. Following these guidelines are not required for
practice, but are considered part of the "standards of care" within the
community. Should legal action be taken against a physician or midwife,
these guidelines will be reviewed, and used as a standard against which
the outcome could be judged.
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