Pennsylvania may soon expand the potential midwife pool by allowing for a new class of "certified professional midwives," a move partly driven by a 2008 court ruling.
Right now, there's no such class of midwives in Pennsylvania, although 28 other states allow them.
In Pennsylvania, those who deliver babies at a midwife center or at a hospital are "certified nurse midwives," carrying both a nursing degree and midwife accreditation, and licensed by the state's medical board. It also means they have some kind of collaborative or contractual relationship with a physician.
And it means that even though certified nurse midwives are permitted to attend to home births, they probably won't because they are employed by a medical provider or a midwife center.
As a result, midwives who are willing to deliver in-home aren't licensed by the state and are operating under the radar with varying levels of qualifications, even though most have some kind of training through an outside accrediting organization.
"We don't license anyone who isn't a nurse," said Ronald G. Ruman, spokesman for the Department of State. "That's where [we] are at the moment."
But a change in state regulations, now being drafted by the Board of Medicine, would allow for a second category of professional midwives, an occupation that does not require a graduate or nursing degree, but would still require training, certification and completion of the state's licensure process.
In the states that allow for certified professional midwives, most limit what those midwives can do and the medications they can administer to mother and newborn. Certified nurse midwives, on the other hand, have greater freedom to prescribe drugs.
Why the proposed change? Allowing professional midwives removes one of the barriers to becoming a midwife, which would allow for more birth centers and more at-home births. It could help temper the astronomical cost for birthing a child -- a midwife-guided pregnancy and delivery ($6,000) costs less than a hospital delivery (up to $50,000 with almost $10,000 for the delivery alone), while at-home delivery costs less still.
A rule change could also allow midwives to operate independently, rather than being attached to a hospital or collaborating physician.
Another reason? Look to Lancaster County. Or, rather, the Amish community, which has been campaigning for years to change the state's laws because of the prevalence of at-home births in the sect.
The state, in a bulletin issued this summer, said the potential rule change was partly driven by the Commonwealth Court's 2008 decision in Goslin v. State Board of Medicine, a case that arose after Diane Goslin, a Lancaster County midwife who had attended to numerous Amish home births, was fined $11,000 and issued a cease-and-desist order by the board.
The judges, in the ruling, reversed the fines, suggesting that state law was blurry on the issue (and suggesting, in an earlier opinion, that "the Court finds the imposition of an $11,000 fine [as] not only punitive but also repugnant to traditional concepts of justice)." Ms. Goslin is certified by the North American Registry of Midwives, which does not qualify her to work in Pennsylvania, in the eyes of the medical board.
Medical boards and doctors groups are often wary of the practice of at-home birth, but midwife groups say the purported dangers of home births are exaggerated. A 2010 analysis in the American Journal of Obstetrics & Gynecology said that neonatal death occurred less than once in 1,000 hospital births, against two in 1,000 at-home births, a statistically significant difference, but not one that represents a big risk.
"The [medical] board has been basically at a stalemate with the midwives associations," said Susan Jenkins, legal counsel the Big Push for Midwives Campaign, a coalition midwives group in Washington, D.C.
The new category of midwife is "very important for Pennsylvania," she said. "Without licensure, women and families really don't know whether the midwife they have contracted with is qualified."
After the medical board approves a draft, the public gets a chance to review the rules and comment on them, as do various legislative committees. Then the regulations are revised, reissued for public and legislative consumption, and sent to the Independent Regulatory Review Commission for final vetting.
The Board of Medicine, in its bulletin, said the new rules would "provide for the licensure of 'certified' midwives," and would "authorize the board to issue rules and regulations as may be necessary for the examination, licensing, and proper conduct of the practice of midwifery by midwives."
Any changes will take a while -- six months to a year, if not longer, "depending on the complexity of the proposal" -- to sort out the exact language of the new rules, Mr. Ruman said.
A more immediate issue for midwives, and particularly midwife centers, is a change in how those centers are paid by the state's Medicaid program.
The 2010 Patient Protection and Affordable Care Act, which requires all state Medicaid programs to cover deliveries at free-standing birth centers, also requires Medicaid to make separate payments to birth centers and to the practitioners.
Currently, Pennsylvania's Medicaid program makes lump payments to birth center professionals every trimester. The new payment method treats midwife centers more like hospitals, compensating both the medical professional as well as the medical facility.
This way, birthing centers get money directly from Medicaid and don't have to "eat the cost" of a Medicaid-covered birth, said Kate Bauer, executive director of the American Association of Birth Centers, based in Montgomery County.
But midwife centers -- there are five in Pennsylvania with one in Pittsburgh, The Midwife Center for Birth & Women's Health in the Strip District -- say that the payments made by Medicaid under the new methodology still won't be enough to cover the costs of a delivery.
Christine Haas, executive director of The Midwife Center for Birth & Women's Health, said at the Pittsburgh birth center the average cost for a delivery is about $5,700. The state is proposing that the "maximum allowable payment to the birth center over the course of all three trimesters, when a delivery occurs at the birth center, will be $1,328." If the delivery begins at a birth center, but then is moved to a hospital, the facility gets only $628.
The most a midwife can get, over the course of three trimesters and delivery, is $1,060.
Low Medicaid reimbursement is one reason many U.S. midwife centers (but not the one in Pittsburgh) turn down or cap Medicaid coverage.
While grateful that the Affordable Care Act mandates payment to birth centers -- eliminating the possibility that such coverage could be axed as a cost-cutting measure and setting the bar for private insurers to cover the same -- Ms. Haas said miniscule payments for midwife-guided births are short-sighted state policy.
If Medicaid isn't accepted by a midwife center, that mother ends up delivering at a hospital -- which costs the state, and its Medicaid program, far more money.
About 40 percent of U.S. babies are born to a mother receiving Medicaid benefits, by various estimates, and in Pennsylvania, it's about 45 percent.
Bill Toland: firstname.lastname@example.org or 412-263-2625.