According to a recent report published by the Institute of Women’s Health at George Washington University, in states where nurse-midwives are permitted to practice without the supervision of a physician, patients have greater availability to medical care. Other research shows that patients of nurse-midwives have lower rates of epidural usage during delivery, as well as undergo fewer cesarean sections.
“It is really hard to argue with the evidence about the value that midwives offer pregnant women,” says Brynn Rubinstein, senior manager for transforming maternity care of the Pacific Business Group on Health. “They are delivering more patient-friendly care, yielding better outcomes and saving money for purchasers.”
So why are California doctors and hospitals at an impasse about whether to pass a bill that will allow hospitals to hire nurse-midwives directly?
Nurse-midwives offer benefits to patients, yet are “not always easy to find”
Across the country, there are over 11,000 practicing nurse-midwives. More than 10% of them are here in California. Still, Rubenstein says of these medical practitioners that not only provide maternity care, but also family planning services and other primary care for women: “They are not always easy to find.”
And if a bill amendment currently hotly contested goes the way medical doctors would have it, certified nurse-midwives might be harder to find…at least in hospitals.
Though the California Medical Association (CMA) and the California Hospital Association (CHA) are on opposing sides of this matter (the CMA represents physicians), both associations are in agreement with the broader goal of the bill: enabling nurse-midwives to treat patients without the required supervision of a doctor. Current law mandates that nurse-midwives must only practice under physician oversight (but not licensed midwives, who have been allowed to practice unsupervised since 2013, though their training requirement is notably lower than that of certified nurse-midwives).
CA in the minority in demanding full supervision for nurse-midwives
California is among just six states in which this type of full supervision for nurse-midwives is required. The bill would override that. And both sides concur that certified nurse-midwives possess the necessary skills and training to practice without doctor oversight.
An amendment to the bill is where the two sides have not been willing to shake hands.
Where the agreement between the CMA and CHA regarding nurse-midwives breaks down is an issue already familiar to the associations: California’s ban on what’s referred to as “corporate practice in medicine.” The state does not permit corporations (and hospitals are classified as such) to directly hire doctors (barring some exceptions). The intended purpose of this prohibition is to steer clear of any potential “corporate influence” that may impact physicians’ practices or decisions.
Although at the present time hospitals are allowed to hire nurse-midwives, many do not, no doubt due in part to complications arising from the inability of nurse-midwives to practice independently. Not only do nurse-midwives need to find physicians that will agree to supervise them, but they also need to pay the physicians for the supervision—and often they must additionally pay more in malpractice insurance.
Assemblywoman Autumn Burke, who co-authored the bill, recently rescinded an amendment to the bill similar to the law that prevents hospitals from directly employing doctors. Since then, the CHA has supported the bill and the CMA, citing concern over the possibility of hospital administrations yielding influence over nurse-midwives they employ, has opposed it. Therefore, the CMA has said it will only throw its support behind the bill if the corporate-ban provision is restored.
On the other side of the impasse is the CHA, who—you guessed it—has said will promptly withdraw their support from the bill if the amendment is brought back. The CHA does not want to surrender the prerogative for hospitals to directly hire nurse-midwives.
In search of a meeting of the minds, Assemblywoman Burke’s office is communicating with representatives of the CMA and CHA, says Allison Ruff, a senior aide to Burke. “For both of them, it is an issue they don’t want to compromise on,” she adds. “The bill became a pawn in the fight between the hospitals and the physicians. It still is.”
And amidst the CMA/CHA volleying, where are the nurse-midwives themselves?
Perhaps Linda Walsh, president of the California Nurse-Midwives Association, encapsulates it most succinctly: “We are very much caught in the middle.”
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