Doctors, hospitals tussle over role of nurse-midwives

A California bill that would allow certified nurse-midwives to practice independently is pitting the state's doctors against its hospitals, even though both sides support the main goal of the legislation.

The California Hospital Association and the California Medical Association, which represents doctors, agree that nurse-midwives have the training and qualifications to practice without physician supervision.

But they differ sharply over whether hospitals should be able to employ midwives directly -- a dispute the certified nurse-midwives fear could derail the proposed law.

"We are very much caught in the middle," said Linda Walsh, president of the California Nurse-Midwives Association.

The bill would override an existing law that requires certified nurse-midwives to practice under the supervision of medical doctors. California is one of only six states that requires full supervision. Several other states mandate other forms of collaboration, such as in prescribing medications.

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The American College of Nurse-Midwives has been chipping away for decades at state laws that require physician supervision, and it has finally passed the tipping point nationally, said Jesse Bushman, director of federal government affairs for the organization. Nurse-midwives aren't seeking permission to go off and do whatever they want without consulting anyone, Bushman said. "They're just asking to be able to do what they are trained to do."

In states where nurse-midwives can practice independently, there is more access to care, he said, citing a recent report published by the George Washington University's Jacobs Institute of Women's Health.

There are more than 11,200 nurse-midwives around the nation, including about 1,200 in California. They provide maternity care, family planning services and other primary care for women.

In 2013, California eliminated the physician supervision requirement for licensed midwives, who require significantly less training than nurse-midwives. Unlike licensed midwives, certified nurse-midwives must become registered nurses and obtain a graduate degree in midwifery. They primarily deliver babies in hospitals, while licensed midwives usually work in homes or birth centers.

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Walsh said her association is trying to make it easier for certified nurse-midwives to practice around the state, especially in areas where there may not be any obstetricians. It can be challenging to find physicians willing to oversee nurse-midwives, because of the responsibility and liability involved, she said.

"We have an access issue in California," Walsh said. "Yet we have this supervisory language that prevents an increase in access for the people who need it most."

Lisa Catterall, who works in a hospital-based midwifery practice at Feather River Hospital in Paradise, Calif., said getting physician supervision is not easy. For one thing, some nurse-midwives have to pay extra malpractice insurance in addition to paying doctors for their supervision. Even with the supervision, the doctors are not required to be present to oversee the care, added Catterall, who delivers about 100 babies a year and sees patients from throughout the rural region north of Sacramento where her hospital is located.

The debate between the doctors and the hospitals centers on the state's prohibition of what's known as the "corporate practice of medicine." California does not allow corporations, including hospitals, to hire physicians, though there are several exceptions. The intent of the ban is to avoid undue corporate influence on doctors' medical judgment and patient care. Under current law, hospitals can hire nurse-midwives, though many don't.

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One of the bill's co-authors, Assemblywoman Autumn Burke, recently withdrew an amendment that would have mirrored the law applying to doctors by barring hospitals from hiring nurse-midwives. With that provision withdrawn, the California Medical Association now opposes the legislation and the California Hospital Association supports it.

The physicians' group believes that the health care decisions of nurse-midwives employed directly by hospitals could be influenced by their administrators, and it says it will only back the bill if the amendment is reinstated.

Patients should have the same consumer protections whether they see a nurse-midwife or a doctor, said Juan Thomas, a lobbyist with the medical association. "It should be a level playing field," he said. "We believe very strongly that the corporate practice of medicine bar language provides an important layer of patient protection."

The California Hospital Association, meanwhile, won't support the bill if the amendment is reinstated. The association believes hospitals need to retain the freedom to hire nurse-midwives.

A ban on hiring would make it more difficult for nurse-midwives to work in hospitals, forcing them into roundabout contracts that are "unduly cumbersome, unduly burdensome and unnecessary," said Jackie Garman, a vice president of the hospital association.

In addition, Garman said, some nurse-midwives are already employed by hospitals. "What happens to them?" she asked.

The nonprofit Pacific Business Group on Health recently announced its support of the midwife bill, saying it would help expand women's choices in pregnancy care and lead to better maternal health. In the spring, the group had sponsored a roundtable with more than 30 organizations from around California to discuss increasing access to nurse-midwives.

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"It is really hard to argue with the evidence about the value that midwives offer pregnant women," said Brynn Rubinstein, the group's senior manager for transforming maternity care. "They are delivering more patient-friendly care, yielding better outcomes and saving money for purchasers," she said. "But they are not always easy to find."

Research shows that patients of certified nurse-midwives have fewer cesarean deliveries and lower epidural rates.

Assemblywoman Burke's office is continuing to talk to representatives of both the physicians and the hospitals to try and find a solution to the contentious issue of whether hospitals should be allowed to hire nurse-midwives, said Allison Ruff, a senior aide to Burke.

"For both of them, it is an issue they don't want to compromise on," she said. "The bill became a pawn in the fight between the hospitals and the physicians. It still is."

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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