HOUSE BILL 1056 HEARING

STATE HOUSE, ANNAPOLIS, MARYLAND

15 MARCH 2012

TRANSCRIBED BY: Nikki Williams, Deirdre Elvis-Peterson, Lynette Telford

POC: Nikki Williams, nikki@bedheadbirth.com

BEGIN TRANSCRIPT:

CHAIRMAN DELEGATE PETER HAMMEN: House Bill 1056 is titled 'Health Occupations- Midwives. Delegate Kelly.

DEL. KELLY: Thank you Mr. Chairman, members of the committee. I appreciate your time on this incredibly important and time-sensitive issue. House Bill 1056 as amended-and you should have some amendments before you-would lift a ban on Certified Professional Midwives in Maryland. It would establish a registry within the Department of Health and Mental Hygiene for these credentialed midwives, similar to the registry we had before the ban was put in place. It would pull together a workgroup to determine a path toward licensure and regulation for Certified Professional Midwives. Twenty-six other states already do this, with no problems, and it's very important to me--and I think to all the people behind me here--that we find a way to deal with this situation. It is very time-sensitive. I would like to point out that--as I understand it, I just got some amendments from DHMH, and they are interested in supporting this bill with amendments, including some changes to the proposed workgroup. It's unclear to me if the amendments also include lifting the ban, and I think the critical thing we need to talk about here.

There seems to be some consensus that we need to address this issue that is before us. It is important that we deal with this right now, but the best way to move forward in dealing with this is having all the folks at the table. Right now, we can't have that because the Certified Professional Midwives are not able to legally practice in Maryland. They're not able to come to the table without fearing that they are going to be prosecuted for practicing nursing without a license. So we want a workgroup that is going to be able to address these concerns realistically, and in order to do that I really think we need to address the issue of the ban. So that, I think, is the crux of this discussion today. Right

now, we have Certified Professional Midwives attending births in Maryland, and they're fearful that they will be prosecuted for practicing nursing without a license, and that has happened. The current situation, where CPMs who attend homebirths are isolated from the rest of the medical community, is not in the best interest of pregnant women. I think that makes sense to everybody here. If you have a midwife attending your homebirth, and they're afraid that they're going to be prosecuted if they transfer you to a hospital in case of emergency, that is a public health problem. It's a crisis and we need to deal with it.

On the topic of licensing Certified Professional Midwives, I will tell you that it is, in my opinion, safe. It would save the system money, increase access to qualified providers, and it's the right thing to do. The midwife ban came into place in 1978. There was a law that we passed that basically said that midwives who are not nurses were no longer midwives. [Laughter] Prior to that, they had been licensed directly through DHMH from 1910 to 1978. Prior to that, they weren't licensed at all; people had babies and they used midwives. [Laughter] But after 1978, what happened was, DHMH had an administration bill, and they basically said they wanted a more modern approach to the practice of midwifery, and basically came to us and said that licensing midwives--who were not at the time Certified Professional Midwives, because that credential did not exist--it was too much work. The present law and regulation placed the Department of Health and Mental Hygiene--this is from their letter of support for the 1978 ban--'placed the Department of Health and Mental Hygiene in a position of a school for training lay midwives, for which we are not qualified. ' That was the situation on the ground in 1978. The landscape has changed quite a bit since then, and you'll hear from folks who work with Certified Professional Midwife credentialing, so you can understand about that. But even at the time, in 1978, this was extremely controversial. The Maryland Nurses' Association opposed the ban; they said 'As we all know, sometimes laws have unintended effects,' and I think that is what we have seen here with this ban. We also have in that file from 1978 a letter of opposition from the American College of Nurse Midwives, who said, 'As the individuals most directly affected by this legislation, we were ignored during the drafting of the bill,' and 'We recognize the health of the women of Maryland should be protected while alternative health care is preserved.'

That's the issue at stake here. It's incredibly important. The ban does, in effect, prevent most Maryland women of my generation from being able to access a legal homebirth or birth center birth, and a lot of us are really ticked off about it.

We do have a handful of nurse-midwives who can attend homebirths. The number I have is five of the 220 Certified Nurse-Midwives; I believe the Nursing Board has a number that's nine, so there's a little discrepancy there, but I've been able to meet and talk [to] about five. And one remaining [freestanding] birth center. But for most women in Maryland, this choice is not legally accessible. Our outdated law is not stopping women from making this choice, and you have in your packets an article from the Baltimore Sun that appeared in January--January 29--and it quotes about five hundred births--homebirths--in the state of Maryland. The number is increasing and increasing rapidly.

We need to address this situation this year, so I hope that we can do that. The current law is forcing midwives underground, and preventing the state from ensuring they are properly trained and effectively regulated. This is certainly not in Maryland's best interest, from a public health perspective, or a women's rights perspective. In the late 1980s, the Certified Professional Midwife credential was established, and the national trend against banning midwives shifted. States began to recognize and license these midwives, who are specially trained in out-of-hospital births. Now 26 states license them, and Maryland should join them. As I mentioned, I believe it is safe. I believe it will increase access to providers and reduce costs, and I believe it is the right thing to do.

On the point of the fact that it is safe, you have a statement in your packet from the American Public Health Association supporting licensure of Certified Professional Midwives, so you can read the full statement. There have been numerous studies on this issue, and our colleague, Delegate Morhaim, actually contributed one of his Ph.D. students to research this for us. She didn't have a position on this bill, and she still does not, but there's a memo from her in your packet that basically evaluates this giant pile of research, but if you want to look at it, I have it. It says that planned--importantly--planned homebirths for low-risk pregnancies have birth outcomes equal to hospital births, and significantly lower c-section and other intervention rates. So this does help women in many ways, but also bring down costs.

There's another sheet in your packet that talks about something called the Wax paper. There are some other studies out there that you may hear opponents of this type of licensure quoting. It's an important distinction, so I'll take your time to make it. The couple of studies that show that homebirth may be dangerous are actually including in those studies unplanned homebirths. It's a huge, different population . A Certified Professional Midwife helping a woman with a

homebirth, who has received prenatal care and is thoughtfully doing this, is obviously a population of folks who are going to have better outcomes. They are the ones who are intended to be covered by this legislation. An accidental homebirth is much more likely to be someone who did not necessarily have prenatal care, is in a difficult situation, someone who our colleague, Delegate Costa, might find as a firefighter and deliver their baby. They were included in this study, so that's why those are bad numbers. So keep that in mind if you hear some opposition. Be skeptical if they are saying that it's more dangerous. We're talking about planned homebirths here.

On the point of it saving money and increasing access to care, I just want to point to this study that was commissioned by the Washington State legislature after they passed their midwives' bill. They did a report; it estimated that spending was reduced on health care by 5.5 million dollars over four years, just from that one percent of women who were choosing midwives, because a midwife-attended birth costs less, and when you bring down your c-section rate, you save money. That's not why I think this bill is incredibly morally important, but it's something that we all think about--the fiscal effect on the state. So I wanted to share that with you.

The most important reason we need to address this situation, and address it this year, is that it is the right thing to do. This is not a typical scope-of-practice battle. It is not ophthalmologists versus optometrists. Giving birth to a child is one of the most important events in most women's lives, and women deserve choices. We cannot have an unnecessary ban infringing on our right to determine how and where we give birth. I would like to note that if you look at the co-sponsors of this bill, it's a diverse group of people who support this legislation. We don't often have reproductive health issues that have this type of bipartisan support. This is something that people all across the state really care about. I think you saw the rally today; they had hundreds of people there coming out to support this bill. Finally, I would just like to say that this is not about whether you would choose a homebirth or birth center birth, it is about protecting the safety of the women who make that choice. With that I'm going to pass it off to my panel.

JEREMY GALVAN: Thank you Mr. Chairman, Madam Vice Chair, members of the committee. My

name is Jeremy Galvan, and I'm the president of Maryland Families for Safe Birth. We are a non-profit, based in Hagerstown/Frederick County area, a

consumer-based organization working to legalize Certified Professional Midwives in our state. We have hundreds of volunteers across the state, and as you can see we had quite a few come out today in support of this cause. Our petition has almost four thousand signatures, many of whom you should be seeing very soon, as they were delivered to a large number of your offices today.

In January 2011 my son, Samuel, was born at home. As a career firefighter/paramedic in Frederick County, I obviously had some concerns. My profession teaches me everything is an emergency, and so it took a lot of learning on my part to learn all the facts that go along with this, and after a lot of studies and coming to grips with what exactly a midwife is, I found this to be an absolutely safe option for my family, and I supported my wife 100 percent. This organization is comprised of a very diverse group of people. We have Amish people, we have middle-class, White, Black, Asian--all races, poor populations, wealthy populations. Kathleen Kennedy-Townsend was somebody who has supported it very publicly (homebirth rights). We have delegates who have had homebirths. We have lawyers, doctors. This is an issue that affects everybody. It affects husbands, especially our wives, and we want to make sure that, for their births, they are being as safe as possible.

I want to emphasize to you that HB 1056 is not going to make any effect on the number of homebirths, other than to allow it to keep doing what it's doing. It is going up right now with no regulation, and we believe very strongly that it is going to continue to go up, whether or not we have this as a legal option. Our families are going to continue to have homebirths. The Amish are going to continue to have homebirths. That's not going to change, but what can change, and what you have power over, is you have the ability to make us have safe options, and that's what we're here today to ask for, is a safe option. Our CNMs? We have lots of CNMs in our state, only five are attending homebirths. I have all of their names, I've talked with every one of them, I'm on very good terms with all of them. They all support this legislation (the ones who do homebirth). We have a chart on page eight of the packet that we provided you, which shows vaguely where they are. We did miss one before print, and she's in southern Maryland, so take that into consideration. As Delegate Kelly said, 26 states license these professionals. We are strongly encouraging you to go along with this and help us to have this option as well. I really want to emphasize that birth is a nine- or ten-month process, and so women are pregnant right now. Some of them are in this room. Some of them are using a variety of different

midwives. Some of them are using CPMs, nurse-midwives. We want to address the safety of these women right now. We do not want them to be at increased risk because we have to wait another year before we come to grips. But I am very optimistic, and very much looking forward to coming to the table with the other parties that are involved, the Nursing Board, and being able to come to an agreement on what would be the safest way to do this. Thank you for your time.

NICOLE JOLLEY, CPM: Good afternoon Chairman, Madame Vice Chair, and members of the committee.

My name is Nicole Jolley, and I am a Certified Professional Midwife. I am in the District of Colbia, and I am licensed and focus my practice in the State of Virginia. So, I'm a midwife. What does that mean? For me that means I work in partnership with parents during pregnancy. It means that I offer continuous, hands-on support to those parents during labor and birth, and the time immediately following. It means that I provide individualized education and counseling to each family that I work with, and a significant part of that education is dispelling misconceptions about midwifery. Sometimes, a mother will ask me, 'Can I still get an ultrasound?' Yes! Midwives offer everything that is standard within the community, and that means that any screening that you are offered in an OB's office in preparation for a hospital birth is also offered to you by your midwife in preparation for a homebirth. And screening is an ongoing process in pregnancy. Professional Midwives are not only responsible for monitoring a mother's physical wellbeing, but also the psychological and social wellbeing, and should any deviation arise during that time, it's my job to refer a mother to the appropriate healthcare professional. That might be an obstetrician, or an endocrinologist, or a chiropractor, or maybe even a maternal-fetal specialist. But what we see is that the best outcomes happen in communities where these various healthcare professions are integrated, so that's what we're working toward.

Another question I hear a lot is, 'Homebirth? Well, what if something happens?' So I say, 'Like what?' 'Well, what if the mom needs a c-section?' 'Well, then we go to the hospital and get one.' Choosing homebirth does not mean that the hospital ceases to exist. It doesn't preclude you from receiving obstetric care, if that becomes necessary. In fact, my clients and I formulate an emergency care plan at our very first prenatal visit, so we've already reviewed and discussed which hospital is closest, which hospital is preferred, where is the neonatal intensive care unit. Informed consent documents and emergency care plans are

a normal part of comprehensive care offered by Professional Midwives, and it's all of these factors together that encompass the midwifery model of care. It's a woman-centered model that has been proven to reduce birth injury, to reduce trauma, and cesarean section. So I encourage you to support particularly the registry component of our bill. Without it, the workgroup would render itself ineffective, and CPMs would still be at risk of prosecution, and in truth, at the end of this process, will be in the very same place that we are today. So I really urge you to consider that aspect, and I just want to extend a thank you for the opportunity to tell you a little bit more about what I do, and that you've decided to turn your attention to this issue.

IDA DARRAGH: Mr. Chairman and Madam Vice Chair and members of the committee, thank you for the opportunity to speak. My name is Ida Darragh, and I am the Director of Testing and the Chair of the Board of the North American Registry of Midwives. That's called NARM, and NARM issues the nationally-accredited credential 'Certified Professional Midwife.' I'm also a CPM, and I've been a licensed midwife by the State of Arkansas for thirty years, so I've had a lot of experience working under licensure and working with national accreditation. As part of my job with NARM, I am the primary contact between NARM and the states that license midwives--the state agencies that oversee their licensure and registration. I have firsthand experience with the success of licensing, or permitting--based on the CPM--and all of the states that currently do that. There are 26 states that allow CPMs to practice legally. Twenty-four have licensure and regulation, and two have a permit system without regulation. Those are working well, too. About half of the states had a local licensure option before the development of the CPM, and about half of them created those licensure programs after the CPM, and th ose require the full credential in order to be licensed. The earlier states that had their own kind of program--they all took the NARM exam as their state licensure exam, but many still implement their own specific state requirements , or their own evaluation of the training of the midwife. But all of them use the NARM exam to measure the final competencies of the midwives who are practicing. Many of these programs have been in place for 20 to 30 years. No state has terminated their licensure program for CPMs or their licensed direct-entry midwife. No state has had a concern about the outcomes that warranted terminating the program or discontinuing their licensure. That, to me, is one of the strongest statements that can be made for the safety and how well it works in states. Even whether there' s 15 or 20 midwives licensed, or whether there's 80 or 100 midwives licensed, it works well.

It saves money for the people, it saves money for the state, and the outcomes are good. Every state is happy with their licensed midwife program.

NARM sets the standards for the educational component of training, and for the supervised practic that's required of all CPMs. Using the national credential as the basis for licensure assures that all licensed midwives have met the same standards, and it allows reciprocity between states that already have the licensure programs. Using the national credential assures that the essential competencies and knowledge and skills have been evaluated by NARM according to the same standards. All CPMs must demonstrate the knowledge and skills regardless of their route of preparation-- their training, their education, their clinical supervision. They must pass a skills assessment , and they must pass an eight-hour written exam.

Our CPM credential is accredited by the National Commission on Certifying Agencies, called the NCCA, which is the credentialing arm of the Institute for Credentialing Excellence. NARM's accreditation through the NCCA provides a mechanism for the yearly evaluation of the certification criteria, the testing validity, the reliability, and all of the administrative processes. This accreditation means that NARM meets the national standards for certification, and that the CPM credential is nationally accredited. So we hope that Maryland will recognize the value of the CPM as a national credential, and see why we need to have a legal route for CPMs to practice in the State of Maryland. We also require recertification every three years, it has continuing education, peer review. We have an accountability process where we can process complaints and have a review of a complaint that can result in discipline or revocations. All that is built into the CPM process that NARM administers. So I'd be happy to answer any questions about the CPM credential or about NARM, whenever it's time.

CHAIRMAN: Very good. Begin with Delegate Reznick?

DEL. REZNICK: I just have a quick question to the gentleman who runs the association, and I will predicate it by saying that I'm neither for or against this right now, so I'm genuinely curious. You had said that licensing midwives will not increase the number of homebirths. Is that part of your testimony? I believe you said that.

GALVAN: Homebirths are going to continue to rise. My point I wanted to make was that if it does not get licensed, it's not going to lower the number. It's not going to

prevent us from continuing...

DEL. REZNICK: So here' s my question, because we've seen this happen, whether because of new techniques in medicine, or whether because of new licensure requirements, or expansion of scopes of practice. We've seen medical professionals advertise their services, trying to draw customers, if you will, patients away from their competitors. So we've seen, in my neck of the woods, Shady Grove Fertility, constantly on the radio and on TV, advertising IVF treatment. We've seen Dr. Goel and Dr. Boutros advertising their LASIK systems and now iLASIK is new. We've seen dentists advertising new implant treatments. How do we know that a year from now, we're not going to start seeing commercials on the radio or TV saying, 'Don't go to the hospital. Come get a certified midwife and we'll do it at home.'

GALVAN: That's an excellent question. I can say that the families who are having the homebirths and seeking out this provider--there's a lot of research that goes into that outside of just what my midwife tells me. I say that as if I have the birth, but aside from what the midwife told my wife, there' s a lot of research that goes into that. I think that the message of the midwives, from what I've seen, has never been that homebirth is better than a hospital birth or that women should stop going to the hospital or that it is an inappropriate place to give birth. From their standpoint, they are merely trying to make sure that they are able to be there so that if we choose that option, we can contact them. If you look at other states that have done this, say, Texas comes to mind-- they are a very big state that has a lot of CPMs, and I believe Ms. Darragh would be able to comment on this further--you still have a relatively low number of the population seeking to have a homebirth. It's not as if you license them and all of a sudden, everybody abandons the hospital and thinks it's less safe. So, I mean by 'relatively low,' I think their percentage--I haven't seen any state that has more than three percent of the population having a homebirth. I don't believe that's anywhere in the country. So, I don't foresee that being an issue, although I'm not an expert at that, per se, to know 100 percent for sure.

DEL. REZNICK: Well, I don' t think anyone's implying that midwives would try and create a situation to give people a concern about going to the hospital; that's not my implication, and the people who seek this out--that's probably a small number, but I suspect that many people don't know it exists. So if we start hearing on the morning drive on WTOP-- we start hearing advertising for 'Come seek out a midwife!' I would suspect that more people would be knowledgeable about it and would look into it, and presumably, midwives would get more business out of it.

GALVAN: In a perfect world, what I would hope to see is that the midwife community, as an integrated part of the maternal care community, would be working with obstetricians and with nurse-midwives in a way that anybody who has a question about the options of homebirth--one day I would like to see that obstetricians would be able to answer that with anything other than a 'No, this is a horrible idea.' So, I would say that that is the end goal, that the different groups can work together, and if a woman has any questions about whether she should be--this is a question she should be able to go to her primary care provider, and be able to go to her OB, go to a midwife, and get those questions answered in an appropriate way. I think it will take time before we see obstetricians, and even some nurse-midwives, and even some other maternal care providers, pediatricians, understanding exactly what the profession is, and once that starts to happen I think it will be a much more fluid system.

DEL. REZNIK: Great. Thank you, Mr. Chairman.

CHAIRMAN: Thank you. Delegate Kipke?

DEL.KIPKE: Mr. Chairman. Under this licensure, would midwives be allowed to do any kind of anesthesia or pain management?

DARRAGH: No state allows midwives to administer pain medication. That's not within our scope, it's not within our training, and it's just not allowed anywhere. They do allow certain medications for emergency hemorrhage, and they do allow the standard medications you give a baby, like eye antibiotic and vitamin K. Each state will have a list of appropriate medications and the appropriate use that are vetted by their licensure board and specifies exactly how they are to be used, but pain medication is not ever on that list.

DEL. KIPKE: So, what about local anesthesia?

DARRAGH: Well, for suturing, to numb the perineum if it needs to be stitched, yes, those are allowed.

DEL. KIPKE: So, when a mother makes a decision...to follow up on what my friend, Delegate Reznick, was asking, if there were to be advertisements, for example, more people would find out about this, if it were to pass, would one of the major decisions that get made by a pregnant mother be based on the pain management aspect of it?

DARRAGH: I think that may be a reason why people decide not to have a homebirth, if they are afraid of the pain, and they don't want to deal with that issue, but they don't get medication for pain relief at home if that's what you're asking.

DEL. KIPKE: Yeah, that's a good answer. Now, some of that's been a burning question for me, in deciding whether or not to support this, is--I imagine the vast majority of instances when a midwife is assisting with the delivery of a baby, it's a great experience, and I've heard that from many constituents in my district. But the question-- as someone who is going to vote on something based on public health-- that I ask myself is, well, in those instances, rare that they may be, do risks increase by not being in a hospital facility? So, if there is the need for an emergency c-section or there may be other complicating factors related to the heart, or to the lungs, or anything else that happens when someone is delivering a baby, do the risks increase by being at home and not in the hospital? What I'd like to know, and if it would be best to have this information--if it's available-- by email, so that we all can see it. Are there peer-reviewed studies or examples that can be provided? So my question is, do risks increase, and two--it's a risk that somebody is taking on voluntarily, I'll definitely admit that--but do risks increase? If your answer is no, can you provide data that is peer-reviewed, scientifically based to help us understand that?

DARRAGH: You know, there's just no such thing as 'no risk at all,' regardless of the site that you're delivering in. Your chance of major abdominal surgery is over 30 percent if you're in a hospital, so you have to balance that out a little bit. The CPM's primary training is in risk assessment. That is the basis of all of our skills. We want to evaluate constantly-- throughout the pregnancy, and the birth--the mother's health status, and our specialty is moving them into the medical system before there's a crisis. When people say, 'What do you do when you need a cesarean?' We're already there, when that decision's made. We're not rushing in to get a cesarean, we've been there for a couple hours, and they're evaluating the need for a cesarean. So we have very, very few emergency transports. That study done on CPMs that was published in 2005 in the British Medical Journal showed that all of the rate of transports is 11 percent, 11 to 12 percent. The emergencies were only three percent, and even with that, those emergencies were addressed appropriately when they get to the hospital. So the outcomes for a homebirth with a qualified provider--a planned homebirth with a qualified provider--are not any riskier than any birth in a hospital would be. If you have a planned homebirth with a qualified provider.

DEL. KIPKE: Will you make sure that's emailed, because I'd really like to read that report and understand it.

DARRAGH: All right.

DEL. KIPKE : Thank you very much. Thank you Mr. Chairman.

CHAIRMAN: Thank you. Delegate Tarrant and then Delegate Costa.

DEL. TARRANT: Thank you Chairman Hammen. Thank you for coming out and bringing out such a beautiful audience. I want to follow up on Delegate Kipke's question. Seventeen years ago, my wife and I had our first child, in a hospital, had an OB/GYN there, and something went wrong. My daughter was turning, she wasn't coming out head first, she kind of was going back up into the womb. First child, I didn't know what was going on, and so all of a sudden, a lot of people started coming in the room. People were coming in with a full mask on, and all this equipment, and they were able to get her out safely, but what I'm wondering, in the situation, with a midwife--how would you be able to handle--and I'm saying this because, like Delegate Reznick said, if it happens that we pass it and then you start advertising--and people think we're real important here. If we pass a law, then it must be good and it's just as good as being in a hospital. How would you handle that set of circumstances when something like that would go awry, when our own board-certified OB/GYN was in serious trouble by herself, and we had to watch these people parade in the room and save my child. So if you could answer that for me?

JOLLEY: Sure, well I certainly can't speak to the circumstances of what happened at your birth. I wasn't there and there certainly would be more information specifically about what exactly the deviation was. First, I would like to address--I think it was the question that the delegate already brought up, which is about advertising--homebirth midwives, because we provide such specific and individualized care, we take six or eight clients a month, tops. So I don't need to advertise for that. I mean, I have people calling me--I'll tell you the truth--I have Maryland clients calling me routinely, and I refer them to the CNMs that are up here. But the truth is, outside the first trimester, their practices are full, because there is such a huge demand for homebirth in your area.

And to answer your question specifically, I'm going to reiterate what Ida said. We are continuously screening and evaluating for any deviations. We routinely listen to the fetal heart tones. It's a really good indicator of how the baby is thriving. We're checking the mother's vital signs, and that's a good indicator of

how she's thriving. We're evaluating how the labor is unfolding and progressing, and so that really tells us a lot of information about the wellness of both the mother and the baby. And, certainly, being in an out-of-hospital environment, we would respond more conservatively. You are not going to wait until it has hit the fan to make a move. If there is a concern, our first concern is safety of the mother and child. I feel like a lot of people, you know when we hear the talk about homebirth, they say, 'Oh, the mother chooses a homebirth because of the experience she wants to have.' And certainly that's a certain part of the decision-making process, but the truth is, these families have done a lot of research, and they have gathered information about what's important to them. And the truth is, birth is safe. Interventions are risky. When you interfere with a process that is so perfectly designed, you are much more likely to see those deviations. So I hope that answers your question.

DEL. TARRANT: It actually doesn't. What I'm saying to you is--it's simple. My child is sixteen now. When I go wake her up in the morning, she goes under the covers. This is just who she is, and she did the same thing before she was a day old. She just disappeared. I mean, really! She's got a learner's permit, but she will disappear when I go in her room in the morning. So what I'm saying is--and that set of circumstances where you've got an OB/GYN standing there, she can't get her out, and she's turned around and gone back up in the womb-- and I'm saying, what types of things do you do to kind of help this in that situation...

JOLLEY: Well, in that particular circumstance...

DEL. TARRANT: And I'm not saying that you should solve my--I know I'm coming to you with a specific issue, of my child's birth experience as a dad on the sidelines--but I'm just wondering, you know, this is a board-certified OB/GYN that had to get a lot of people in that room because she could not help my wife or child. So I'm saying, what happens in your situation? What do you do when that situation arises and you're not in a hospital?

JOLLEY: So a baby receding into the womb is not a life--not a critical issue. I mean there may have been complications with your baby's hear t tones-- I don't know why they all rushed in, but a baby moving higher up in the birth canal is not a problem. So it's challenging for me to answer your question specifically.

DEL. TARRANT: Okay.

JOLLEY: In a homebirth environment, if the baby were not descending, and in fact it seemed as if the labor was not progressing in an appropriate fashion, we would

transport to the hospital. If there is an indicator there's a problem with the baby, we would transport to the hospital. Does that answer your question?

DEL. TARRANT: So the next phase--you would transport?

JOLLEY: Certainly, and the mother--they may decide at the hospital that a cesarean section is the safest route of delivery for this mother and baby. But that's a bridge that you cross when you get to it.

DEL. TARRANT: Okay.

JOLLEY: As for your teenager getting out of bed, you might try forceps. [Laughter]

DEL. TARRANT: Thank you.

CHAIRMAN: Okay. [Laughter] Delegate Costa, then Delegate Murray.

DEL. COSTA: Let me try to make this a little bit easier to go further with what my colleague was just asking you. The pregnant mom actually goes through nine months of prenatal care, sonograms, visits with the OB/GYN at times as well, is that correct? So you may see your dangerous delivery issues may potentially already be identified so you can prepare for that whether it's going to be at home or in a hospital, based on presentation through sonograms and things like that. Am I correct?

DARRAGH: I'm not sure if you meant, 'Does every midwife client get all her care from the obstetrician?' The midwife actually provides that, all that prenatal care.

DEL. COSTA: Right. But you have access to identify...

DARRAGH: We have done all the assessments all the way through, yes.

DEL. COSTA: So a lot of the more high-risk pregnancies, you have already planned that maybe the in-home delivery might not be what's best.

DARRAGH: Right. They're already referred out. If the baby's not in a good position, they don't have it at home.

DEL. COSTA: There are standard protocols that you all use in regard to a prolapsed delivery or a limb that is presenting itself. You already do that, correct? There's protocols on what to do if that's the situation?

DARRAGH: There's protocols for what to do. We have-

DEL. COSTA: Are those protocols any different than what an OB/GYN would do?

DARRAGH: Other than for surgery, we would have to, you know-

DEL. COSTA: They're exactly the same, correct?

DARRAGH: They would be the same.

DEL. COSTA: They're exactly the same for firefighters, am I correct?

GALVAN: I would think so.

DEL. COSTA: They are. So what you're doing actually is no different, depending on the presentation that's there, that every other licensed professional does exactly the same, am I correct?

DARRAGH: That's right.

DEL. COSTA: Thank you.

CHAIRMAN: Delegate Murphy then Delegate Nathan-Pulliam.

DEL. MURPHY: Thank you Mr. Chairman. It says in the fiscal note that Certified Nurse-Midwives have to have a collaborative practice agreement with physicians. Does this bill require that the Certified Professional Midwives would have to also have a collaborative agreement with physicians?

GALVAN: The consumer group would advise strongly against a collaborative agreement with physicians. This bill does not decide that [Darragh whispers]--because of the amendments, it's not deciding that. I apologize. We would advise strongly against the collaborative agreement. If you look at a state like Delaware, where they have licensed their CPMs, they have a collaborative agreement in place that they have to follow, and because of that, there are no CPMs. Because obstetricians will not sign a collaborative agreement with the CPMs. It's a really kind of oddball, interesting little scenario. The doctors kind of got what they were looking for there. So they put them out of business. That would obviously be a problem for us.

DEL. MURPHY:I don't know exactly why that may be, other than maybe some liability issues, but that brings me to another question, and we're talking about some of the dangers here. In my area, we lose obstetricians because they say they cannot afford the premiums for the insurance. What types of insurance do you carry that may protect families that may have an unfortunate--

GALVAN: There have been health insurance plans available throughout the country that other midwives have been able to--excuse me, that CPMs and other non-nurse-midwives have been able to use. In the State of Maryland, it does not require healthcare providers to carry professional liability insurance, and so we would obviously go along with what that requirement--

DEL. MURPHY: Well, that's fine, I understand that. But I'm thinking about, now, from the patient and the mother's standpoint. If there in fact is a birth that is not the way they expected it to go, what recourse do they have, then?

GALVAN: I apologize, I didn't understand your question.

DEL. MURPHY:Well, what I'm hearing you say is that you're not requiring that they carry liability insurance, is that right?

GALVAN: That's right.

DEL. MURPHY:Okay. That satisfies the midwives. I'm asking on the other side, of the parents and the child, if the birth does not go the way--that there's some issues or whatever--what do they have in terms of any recourse?

JOLLEY: Perhaps I can help with the answer to this question. So, certainly in that scenario, the parents have the opportunity to file--most often with the state, and I know that's how it works in Virginia--and we have the North American Registry of Midwives. And so if it is found that a midwife is not practicing within her scope, or if there was an error, that midwife will very likely lose her privilege to practice.

DEL. MURPHY:I get that. I'm asking now for the parents of that child, who may not have had a successful birth. What recourse do they have?

JOLLEY: I believe the next option would be a civil suit.

DEL. MURPHY:Okay. All right. Thank you.

JOLLEY: You're welcome.

CHAIRMAN: Okay, let's turn to Delegate Nathan-Pulliam.

DEL. NATHAN-PULLIAM: I'm over here. I just want you to let me feel comfortable about moving forward,

and the reason for that--my first six years of my nursing career, I was the OB/GYN nurse at the then-Baltimore City Hospital. So I know how very quickly a person comes in in labor, and I find I have a breech on my hand, a preeclampsia

patient, or I have a placenta previa. They've got to go immediately to the operating room. What do you do if those situations occur, that you did not know about previously? What do you do? I just want to feel--for me to feel comfortable.

JOLLEY: Sure. So certainly in that circumstance, the first thing that we would do is to engage Emergency Medical Services. However, CPMs take extra precautions and care prenatally to ensure that the mother they are serving is fit for homebirth. We use Leopold's maneuvers to evaluate the position of the baby at every prenatal visit. We use ultrasound if those findings are unclear. We use ultrasound in the case of placenta previa. We are doing routine urinalysis and checking vital signs during every prenatal visit. Those things often rule out preeclampsia, and the truth is, you know, you can get struck by lightning. You're not going to eliminate that, but you know firsthand, that you don't eliminate that by giving birth in the hospital, either. And I feel like, as people, homebirth certainly is something that we don't hear about every day. But in life, you assume a normal level of risk in many things you do. You know, there is risk in crossing the street; it doesn't mean you only cross the street in front of the hospital.

DEL. NATHAN-PULLIAM: So as you talk about risk, I hear what you're saying. It can happen anywhere.

The only thing, in a hospital setting, an OB/GYN in the delivery room that I worked, the operating room was down the hall, so I didn't have to go far to move my patient from there to the operating room, and even scrub, on that particular case. But what if something happens, then? What kind of liability--I hear some aspect of it. What kind of liability insurance that you carry, in case later on something does happen, and you're sued?

JOLLEY: Well, just like the Certified Nurse-Midwives, who are licensed, we don't carry liability insurance. I'm sorry, what was the other part of your question?

DEL. NATHAN-PULLIAM: That's it. I just wanted to know what kind of liability--so you're saying that you

don't carry any liability insurance at all?

JOLLEY: No. The other thing that I wanted to articulate to you is that, if you look at the research, you don't see worse outcomes with homebirth. I certainly understand that when you think about this scenario, it is intimidating. I hear you say it, and I feel intimidated by it. But the truth is, the outcomes for homebirth are as good as hospital birth, so we're not seeing these scenarios where because there wasn't an OR in the next room...The truth is, like I said earlier, birth is designed to work, and when you are not--in the hospital, sometimes we see what's called 'iatrogenic' issues, when the problems with the labor are caused by intervention.

So of course there's a lower incidence of that with out-of-hospital birth, because we are allowing the natural process of labor to unfold. So I think that's also a factor. The other thing to really remember is that in the hospital, the approach is the medical model. We are offering the midwifery model of care, and they are sort of apples and oranges. I mean, it's a different approach to serving women in the childbearing cycle.

DEL. NATHAN-PULLIAM: I hear you. Thank you very much. The only little part that still bothers me is the

liability piece. The only reason is that, I think, about two years ago I went to the University of Maryland, where they had--they call them--Doctor for a Day kind of course, and at the end of the day, they called out how many people were sent off to the various internships in the different hospitals. There was only one person that came out of that program that was going in obstetrics, and the reason that was given was because of the liability costs, and for that reason, a lot of doctors were not going into obstetrics. So that was part of my second part why I asked you that question. Thank you.

GALVAN: It's also important to note that the paramedics and firefighters do not carry liability insurance either, and we do a job that we run into very similar situations on a regular basis.

DEL. NATHAN-PULLIAM: Thank you.

CHAIRMAN: Delegate Ready.

DEL. READY: Thank you Mr. Chairman. I just have two questions. One is, I am very sympathetic to this bill and I'm a co-sponsor. But I have a few questions and concerns, one of which is--or, my question is, what is the difference between a nurse practitioner midwife and you all? [Laughter]

DARRAGH: The nurse-midwife has a different kind of training, and deals with a broader scope of practice and more complications. The CPM deals with just the childbearing year--the pregnancy, the birth, the first few weeks afterwards. We don't do full-scope woman care throughout the lifecycle, which CNMs generally do. We also have a much more limited use of medications. The standard routine, or the emergency, we don't treat conditions with medications like an advanced practice nurse is usually allowed to do.

DEL. READY: And a nurse practitioner midwife would have liability insurance?

DARRAGH: Only if required by her state. Most states do not require it for a license, but it's sometimes a condition of employment. There is only one state that licenses

direct-entry midwives that requires liability insurance, and that's Florida. And because they require it, the only way they can get coverage, for Florida-licensed midwives, is for the state to provide a Joint Underwriting Association to cover it.

DEL. READY: Because otherwise you wouldn't be able to afford liability insurance.

DARRAGH: Right. And the premiums are still very high, which eliminates the small midwife practice. You've got to have a pretty big practice to pay the premiums, but you can't even get the policies written with that Joint Underwriting Association that is sponsored by the state, and that's the only state that requires liability for midwives.

DEL. READY: And if I can just ask kind of a follow-up--and anybody on the panel can answer--why do people choose your route, when the nurse practitioner midwife can do--if there is a complication--has a wider spectrum of needs, I mean, can do more things if there's some complications. And maybe folks that are going to testify later will get into that, because I know it's a very personal choice.

DARRAGH: I can answer that. The nurse-midwife generally--generally--is trained and intends to work in a hospital to provide that broader scope. Occasionally, they'll decide they want to do a homebirth practice and go into that, but the majority-- vast majority--of nurse-midwives are specifically trained and plan to work in hospitals. CPMs don't work in hospitals. We work in homes and birth centers. There's a little overlap, but there's just a small overlap.

DEL. READY: Because people want--so people who say, 'I would like to have my baby at home,' and accept the risks that come with that--and of course we're going to see how risky it is, probably with some information you're going to get for us--this is about letting those folks have that choice...

DARRAGH: Right.

DEL. READY: Because that's why they don't go to a nurse practitioner midwife because they don't want to go to a hospital, if they can help it.

DARRAGH: They generally don't provide the homebirth services.

DEL. READY: Okay, all right. Thank you, Mr. Chairman.

JOLLEY: Just as a supplement, on page 42 in the packet, there is more information about malpractice and midwives, so if you'd like to follow along, you can find some more information there.

CHAIRMAN: Okay, are there any additional questions, Delegate Morhaim?

DEL.MORHAIM: Chairman, thank you. Delegate Kelly, for putting this bill in, you referenced

some statistics that were generated by one of my staff. Is that in the package? I couldn't find it.

DEL. KELLY: It is, you have a couple different things. One is this spiral-bound booklet that is coming from Families for Safe Birth. In addition, you have something that should be bound, I think, by a paper clip. That's from me, on the front of it is this apple and orange, and just behind that is the memo that your staff member made.

DEL. MORHAIM: Okay, thank you. For Nicole Jolley, I had a somewhat different clinical

experience than Delegate Nathan-Pulliam. Mine is more that almost 99 percent of problems with delivery are identifiable long before the first contraction--underlying disease, all those kinds of things.

JOLLEY: Certainly.

DEL. MORHAIM: So if you had a patient you were taking care of, and those things show up--

diabetes, high blood pressure--you've eliminated them from your practice, right?

JOLLEY: Certainly, and I would refer that patient to the appropriate healthcare provider.

DEL.MORHAIM: And you're currently working in...

JOLLEY: Virginia.

DEL.MORHAIM: Virginia. And how long have you been working there?

JOLLEY: I've been doing birth work for about eight years and practicing independently for the last year and a half.

DEL.MORHAIM: And how many deliveries do you do a month, on average?

JOLLEY: About eight.

DEL.

MORHAIM: And of the patients that you see, how many that come to you initially--how many do you then suggest that they go to another practitioner because you don't want to have a problem?

JOLLEY: It's happened one time.

DEL.MORHAIM: Okay. And of the deliveries that you've had, how's the outcome been?

JOLLEY: Well, I have a very low transfer rate so far--I mean, granted, we're working on a year and a half, but it's at zero. [Laughter] So I would say the outcomes are very good.

DEL. MORHAIM: My other sense is that a lot of things that happen in hospitals are kind of

precipitated by being in the hospital. There's just a lot of things that I observe that were--different aspects of the natural process were interrupted, so one thing cascaded into another, and I think sometimes it would have been better off just to let well enough alone, just to let things happen, it would have worked out better.

JOLLEY: I certainly agree that that's true, and not to downgrade the hospital environment, but they are charged with care of the masses, and when you're caring for a group of people that's that large, it's almost impossible to offer independent, individualized care. So I have the privilege--I'm very lucky to be able to offer care that's very specific to each patient. I think it makes a big difference in the outcomes.

DEL.MORHAIM: Thank you very much.

CHAIRMAN: Any individual questions? Thank you very much. Let's bring out the next panel Erin Fulham, Shelly Morhaim [inaudible], Ann Faust and [inaudible]. Good afternoon, who would like to begin?

SHELLEYMORHAIM: Well, I'd like that end of the table to start this time. [laughter]

CHAIRMAN: Mr. Calvo?

PABLO CALVO:I apologize, I didn't print my statement but I do have it in text message. [Laughter] Thank you, my wife was very, very helpful. Thank you Mr. Chairman, Madam Vice Chair, members of the committee. My name is Pablo Calvo and I live with my family in Baltimore, Maryland. I am a constituents of Delegates

Hammen, McHale and Klippinger. My family has had the unique experience of having a midwife assist in the births of my two sons, Enzo and Massimo, in both hospital and home settings. Each experience was different, but my family was grateful to have had the choice to have a midwife assist us in both cases.

This bill in support of licensed midwifery in Maryland is important to my family for three primary reasons. Our first reason was the safety of my wife, Carmen. As safe as hospitals are thought to be, the steadily climbing incidence of cesarean sections in Maryland gave our family pause. The prospect of possibly having unnecessary surgery for a natural process caused our family severe stress. When my first son, Enzo, was born, we did require a hospital birth due to medical complications during the pregnancy. However, we almost became a cesarean statistic, as the birthing process was not optimal. We were immediately surrounded by literally twenty people ready to wheel my wife off to surgery. Had it not been for our midwife holding everyone at bay, advocating for us and coaching my wife throughout, we would not have had the successful natural birth that we planned as a family. My midwife was the only reason that this could happen. We were so grateful that the same midwife could attend the birth of our second son, Massimo, with little more complication than a nervous father not sure what to do with himself. Our experience was everything that we had hoped for. We were with our family in our natural surroundings, being given much more attentive care than I remember from our hospital experience. This was about the birth of my son, and my family's well-being was the only focus for our midwife, who never left our bedside during the birthing process. In my opinion, that level of care is simply not possible in a hospital.

Our second reason was cost. Our hospital birth cost our family four times as much out-of-pocket expenditures than our homebirth. As a one-income family, these savings impact our financial wellbeing immediately. In a financial climate today, where taxpayers are feeling pressure on a daily basis and from multiple levels of government, our homebirth experience was not only emotionally rewarding, but financially rewarding as well.

Our third reason was culture. I'm a naturalized citizen, originally from Costa Rica. Hispanic culture is highly acclimated to the use of midwives, due to the shortage of doctors and hospitals in many places throughout Latin America. Though that shortage for medical professionals doesn't exist in Maryland, the culture acclimation to midwives is present and should be respected for a growing constituency in our communities.

I end my testimony urging support for House Bill 1056. It matters to families that consider medical choices in determining birth experience--a right that should not be encumbered. Licensed midwifery is the only manner in which this will be possible. Thank you for your time.

ANN FAUST: Good afternoon. Thank you Mr. Chairman, Madam Vice Chair, and members of the committee. My name is Ann Faust, and I live with my husband and four children in Howard County, Maryland. I am a constituent of Delegate Guy Guzzone, Shane Pendergrass, and Frank Turner. I immigrated to America nearly twelve years ago from England, and when I came, I was seven months pregnant. While we were looking to transfer my medical papers from my midwife in England, I was very surprised to learn that there weren't enough practicing midwives for the needs of Marylanders. As a surgeon, part of the medical team, I worked with United Nations and traveled the world. This was really surprising to me, as most of the world, especially in Europe, standard perinatal care--meaning before and after the birth--is almost always offered by midwives. Still, we took the advice of friends, and we went to the obstetric practice nearby our home, and delivered my first baby at our local hospital. Our experience during the whole birth process was less than desirable. There was very little information supplied to us, and my husband was nearly taken out of the whole equation. Again, I am very ashamed to say this--as a part of a medical team, the whole process was very medical and on the verge of abusive.

When we found out that I was pregnant with our second baby, and the first experience under our belt, we decided that this kind of perinatal care was not for our family. We had our second baby again at a hospital, but this time with a midwife. We were discharged from the hospital about sixteen hours later, with the help of our midwife, to adjust to life as a family of four. Three--four, sorry. Having four kids! [laughter] As we all agree, nothing feels like sleeping in your own bed, especially a journey like birth. Learning from our past experiences, we investigated further and chose a CPM to deliver our third baby at home. From our first meeting to weeks after our last checkup after the birth, the care we received beat medical care we had--nurturing, all the information available to us all about the birth options, as well as if something would go wrong, what would be our choices--was immaculate.

Sadly, when we found out that I was pregnant with our fourth baby, we couldn't use our former CPM, as she was facing legal challenges to work legally in the State of Maryland. So we chose another very reputable CNM that we knew professionally, as well as a friend. She was a nurse, and was licensed to practice midwifery in Maryland, so we were set to have our desired birth. Alas, that was not to be either. Again, from the word 'go,' the whole team was very informative, careful, and open with us. They discussed the pros and cons of homebirth in great detail, as well as a backup plan in the unlikely event of things not going according to the plan.

Sadly, nothing could prepare us for the unseen trouble lying ahead. Maryland Board of Nursing suspended our wonderful midwife's license when I was nearly

forty weeks pregnant, leaving me, my unborn child, in deep distress and somewhat danger without the real option for a safe birth. As I was so far into my pregnancy, no obstetrics offices would even consider taking me as a new patient. Only a handful well-meaning, but nearly overworked--due to the lack of homebirthing midwives, and their equal partner CPMs in the State of Maryland--couldn't help me. So we were left with no real choice to birth at home with a qualified attendant, but to deliver our son at home with the help of my husband alone.

CHAIRMAN: Miss Faust, I'm going to have to ask you to conclude, please.

FAUST: Okay. All the parents and healthcare teams work for the safe birth practices in Maryland. Homebirth may not be for every family in our state. But there are families, and these numbers increase every passing year, who choose to have their babies in safe secure, healthy home environments. In the current situation, the handful of homebirthing CNMs provides not enough to answer the demand. Since January 2012, I alone got over twenty-five Maryland families asking me for midwife referrals from our practice. These families are well-educated about their birth options, and seeking alternatives, and unfortunately, some have been driven to choose not a safe way to have their desired births, that I was forced to choose. I hope you agree that bringing in trained and licensed CPMs will help close this gap, as well as regulate the untrained individuals out there. So I am reaching out to you to consider leaving normal birth to the time-tested experts--the midwives, both Certified Nurse-Midwives as well as the Certified Professional Midwives. Thank you very much for your time.

CHAIRMAN: Mrs. Morhaim?

SHELLEYMORHAIM: Hi, my name is Shelley Morhaim and, as I think most of you know, I’m married to

Dan Morhaim, the honorable delegate from the 11th District, and I wanted to just share with you why Dan and I chose to have all three of our children at home attended by midwives. When our first child was born in 1978--and certainly, when we started off on that pregnancy, it was not our intention to have a homebirth. I don’t think it ever crossed our mind. We just wanted the safest, best place to have our baby. We assed that that would be with an obstetrician in a hospital; actually, in the hospital where Dan was, at that time, a third-year resident, which also happened to be sort of the premier hospital to have your baby in Los Angeles. It was a teaching hospital/academic center. But at the time, I was working as a medical malpractice attorney on the plaintiff’s side, and probably about 50 percent of our caseload were obstetric cases, and I started to notice there was a pattern in these cases. Usually it started with a healthy pregnancy, a healthy mother, a normal beginning of labor, then the mother would go to the hospital, and some intervention would happen, whether

it was rupturing the amniotic fluid sac, or it was applying an internal monitor to the baby’s scalp, or possibly giving medication like Pitocin or pain medication. But what happened was one intervention led to a problem, which led to another intervention, which led to more problems and you ended up with injuries, which resulted in the malpractice case. Dan and I started questioning, 'Is a hospital the safest place to have a normal delivery?' And I think it’s definitely the safest place to have a high-risk delivery. You want to have a trained surgeon attending you at that point, but 95 percent of pregnancies are not high-risk, they’re low-risk, and everything goes as has been said according to nature. We were very fortunate that we had a friend who had just completed her midwifery training and was willing to be our attendant. We were also very fortunate that my obstetrician was extremely supportive; unlike many of his colleagues, he didn’t seem to have any ego involvement in making sure that every last woman have her baby in the hospital. So he was very supportive, and he was there should an emergency have arisen. We were lucky everything went well. You know, births are hard. I won’t say it was the most pleasant experience of my life, but it was certainly a high point of my life. It was just a wonderful, wonderful thing to be able to have our babies at home. I would really urge people to--this is, I think, the parents who choose this route, like Dan and I, we are trying to find the safest, healthiest place and way for their babies to be born. So I would urge you to pass this bill.

ERIN FULHAM,CNM: Thank you very much for having this hearing, all of you. My name is Erin Fulham.

I’m a Certified Nurse-Midwife who has been attending homebirths in Maryland for more than twenty years; first as an assistant, and then as a midwife. Currently I have my own practice, MAMAS, in the Silver Spring-Takoma Park area. Having worked in all birth settings: home, birth center and hospital, I believe, for many women and babies, home can be the best choice. Moreover, I believe it is best for all women to choose their place of birth, as well as their care provider, and I believe women are quite capable of making those decisions in a thoughtful manner. I’m both personally and professionally aware of the high quality of care that CPMs offer women and their families. As one of the few homebirth midwives licensed in Maryland, I turn away clients on a weekly basis, serving as a constant reminder that there are not enough nurse-midwives to meet the demand for homebirths in Maryland. I therefore ask this committee, and the Maryland assembly as a whole, to support the licensure of Certified Professional Midwives.

In supporting this licensure of CPMs, the committee will be supporting the right of Maryland women to review the facts and make an informed decision. One of the facts that families review about MAMAS is that we have a six percent c-section rate, compared to our local hospitals, whose rates are above forty percent . The fact is that MAMAS mothers and babies are never separated. Our

babies are never exposed to someone else’s bacteria, such as MRSA. The fact is that we have a 100 percent newborn breastfeeding rate. The fact is that we spend more time with our mothers during pregnancy and birth, and it still costs less to have a baby with MAMAS than in a hospital.

Our families are perfectly capable of researching the facts about their own care and making their own decisions. We offer the standard of care, but more importantly, we offer options and mothers choose what they need based on facts, and the facts are our outcomes are excellent. Homebirth outcomes with a skilled provider are comparable to those at a hospital, and there’s nothing at a birth center that a licensed midwife cannot bring to a family’s home. My partner and I set up for a birth center…for a birth exactly like a birth center. I know this because I’ve worked at every independent birth center in the area. Maryland women want midwives to attend their births at home, but there are not enough midwives. At MAMAS we turn away about the same number of women as we accept, simply because of vole and distance.

Homebirths in Maryland have increased over sixty percent in the past few years. In the beginning of 2010, this committee required the Board of Nursing to implement regulation change to make it easier for CNMs to practice in Maryland; however, since that time no CNMs living in Maryland have been able to start a homebirth or birth center practice. None. Some have tried repeatedly, and still others have been too discouraged by the politics of midwifery in Maryland to even try. Midwives have excellent outcomes because we are the experts in normal birth. I respect and am grateful for the skillful care that our families occasionally receive for from consulting physicians; at the same time, I believe that Certified Professional Midwives who are trained and nationally certified also deserve respect, and should be licensed to serve the women who seek this skilled care. Thank you.

CHAIRMAN: Are there any questions from the panel? Delegate Costa, then Delegate Morhaim.

DEL. COSTA: Thank you Mr. Chair. Mrs. Morhaim, in effect, you still had a physician at your house when you delivered, is that correct?

MORHAIM: That's true.

DEL. COSTA: Thank you. CHAIRMAN: Delegate Morhaim and Delegate Nathan-Pulliam.

DEL.

MORHAIM: Mrs. Morhaim, you’ll testify that I was just running around as a crazy father-to- be. I thought of a number of clever and possibly inappropriate off-color comments to make to my wife, but what I really want to say is, in 18 years of office, this is the first time you’ve come in to testify and thank you for that. And people come to us and say you were so brave to have your children at home. Actually, I thought it’s because we were not brave that we chose to have our children at home. Brave is going to the hospital and having a lot of other things happen when there was no need. That’s what brave is. We were chicken, and so we stayed where we thought it was safe and comfortable and all the right thing. Honey, I love you and thank you for doing the right thing for the kids. [Applause]

CHAIRMAN: Delegate Nathan-Pulliam.

DEL.NATHAN-PULLIAM: Mine is a quick comment and a question. The comment to Delegate Kelly is to

say that you have been well organized. I mean, I’ve been here for a very long time, but just to see the letters and how everything has been formulated, I salute you in terms of your organization.

Now Ms. Faust-- is it Anne? Okay. Let me ask you a question. You indicated that the Board of Nursing--you said, I think it says here, on your very good nurse--oh, 'the Board of Nursing suspended our wonderful midwife...' Licensed. Why-- if she was licensed, why did they suspend her?

FAUST: [Laughter] That’s a good question. To this day, we do not know. They keep postponing their meetings and postponing because-- in the beginning we thought it was just a mistake or whatever it was. They have got three charges against her, none of them has been proved, but Board of Nursing has not yet met with her to, you know, discuss rights or wrongs of these accusations. They’re still standing as accusations, and she is still is not eligible to practice because they pulled her license, both as a midwife as well as a nurse.

DEL. NATHAN-PULLIAM: Well yes, so it’s an ongoing case, is that what you’re telling me?

FAUST: Correct, your honor.

DEL. NATHAN-PULLIAM: Ok and maybe I just want to clarify: I went to nursing school in Yorkshire,

England...

FAUST: I’m from Yorkshire.

DEL. NATHAN-PULLIAM: How the process works is that it’s three years when you finish nursing school,

then you do 18 months of nurse-midwifery, and that was the process to which you go. So most--at least 90 percent--of the nurses that come out and do midwifery are in fact nurses. I just wanted to make that clarification.

FAUST: Within the last ten years or so, they can actually go as a direct entry and they can study midwifery straight away and they do about maybe four or five weeks in classroom, and after that they’re always hands-on practice. They’re always on the wards; they’re always shadowing a qualified midwife as well as obstetrician, and just in and out of wards, as you probably know, in the GP's offices, which most primary healthcare is being handled in the UK, but they are very hands-on, and I’ve been informed that the training they receive in the United States is very similar to that. No obstetrician is just allowed to or ever delivers a baby until they can pass their boards.

DEL. NATHAN-PULLIAM: Yeah, I was pregnant with my first child in England so I do pretty well know about

the system there. But thank you for letting me know what happened in the last ten years, in terms of what’s going on now. Thank you.

FAUST: You’re very welcome.

CHAIRMAN: Delegate McDonough.

DEL. MCDONOUGH: Not only is Delegate Kelly really well organized, but these are the most well-

behaved babies I‘ve ever witnessed. [Laughter]

CHAIRMAN: Okay, I want thank the panel for your testimony here today, we do appreciate it. Thank you very much. Okay, let’s bring up the next panel. Evie Fielding, Heather Brown, Catherine Corbin. I just want to remind everyone of the committee’s three-minute rule. Please try to be brief.

EVIE FIELDING:Yes, sir.

CHAIRMAN: Ms. Fielding would you like to begin, please?

FIELDING: Yes, thank you. Thank you Mr. Chairman, Madam Vice Chair, and members of the committee. My name is Evie Fielding and I live with my family in Catonsville, in the District of Delegate Shirley Nathan-Pulliam. This bill is very important to my family for a number of reasons. By bringing CPMs under the umbrella of a licensing body, it will allow for greater regulation, increased safety of practices, allow more access to safe out-of-hospital births, and hopefully set the stage for

more seamless collaboration among healthcare practitioners as needed. As the daughter of an obstetrician and a cardiothoracic surgeon, I have great respect for the medical field. I had always envisioned a standard hospital birth for myself until I became aware of the many benefits of homebirth. I chose to give birth at home with my first child, because I wanted an experience that was personalized, relaxed and empowering. One that was not over-medicalized or rushed. I was also looking for a health practitioner who had an unhurried manner, who valued the natural birthing process of which you heard about today, who promoted mother-infant bonding, and who was experienced in healthy unmedicated birth. I was referred to my nurse-midwife by a friend, and my son’s birth was attended by a midwife, her birth assistant, my husband and my doula. Our birth team arrived at my home shortly after my labor began, and it felt very comforting to have these trusted people that I knew gather around me and put our birth plan into place. For pain management, I had taken a Hypnobabies course which involves self-hypnosis- the same medical hypnosis that people use when they are not able to use anesthesia for surgery. My son was born seven hours later in a pool in our bedroom, in the very corner in which I nursed and rocked him to sleep many nights afterward. Throughout his birth, I was reassured by the knowledge that should I have needed further medical care, this would have been recommended appropriately. My son’s heart tones and my vitals were taken throughout the process, and I was very comfortable with this.

I’m very grateful that my whole birth experience was something that I cherish and remember with great fondness, and not something that I merely endured. Now that I am happily expecting our second child, I hope to repeat the process again. However, my midwife is no longer practicing due to legal issues that you have heard about, and I have not been able to find a practitioner who can practice legally in this state. So I am faced with having to go out of state for my second birth. By far a very far second choice.

It is startling to me that in a state that values options and choices, and encourages consumers to make educated decisions about their healthcare, that my choices are so limited. Please support House Bill 1056 and allow Marylanders to have the option to choose a safe homebirth and give their children a beautiful start in life. You have heard--and will likely hear--many stories, both horror stories and beautiful stories of birth, and I would ask you to use both your emotions and the thinking part of your brain to make the decision. Listen to the base rate and statistics that you are being offered. I hope that children and their parents will be able to have a choice to have a birth in which people and hope, and not machines and fear, are the guiding principles. Thank you.

CHAIRMAN: Ms. Brown.

BROWN: Yes sir. Thank you to the members of the committee for entertaining this issue. It is all very important to all of us; we’re extremely passionate about it. My name is Heather Brown. I am mother to three daughters, ages six, three and three months. The three-year-old and the three-month old were born at home in Delegate Nathan-Pulliam’s district 10. Yes ma’am. So my journey to homebirth began when I gave birth to my first daughter in a Baltimore County hospital in 2006. After a wonderful healthy labor with absolutely no complications whatsoever, she was born within minutes of arriving at the hospital and was immediately whisked away and taken away from me, without so much as me being able to lay my eyes on my very first child--or my hands. Taken to the NICU for observation just in case when there were no--and I've obtained my records. I’ve reviewed the hospital's records. There was absolutely no indication that she needed any type of assistance whatsoever. Taken to the NICU just in case, and it was hours before I ever laid my eyes or my hands on my first child. So her first moments, which really should have been spent on my chest nursing and bonding and connecting as our family, she spent in a plastic box hooked up to machines, no doubt alone and wondering where the only person she had known for nine months was. That was very traumatic for the two of us, and so when I became pregnant with my second daughter, I knew without a doubt that my right to keep my child with me after birth, my desire to have my older child be part of this experience, to have a family-centered experience, to have the type of personalized care that these ladies and gentlemen have been speaking of, that my best option to do that was without a doubt in my home. My confidence was certainly buoyed by the fact that I was able to find competent midwives who I completely trusted to monitor my condition, to make sure that all was well with mother and baby.

That’s the thing about women who choose homebirth. We are not cavalier with the lives of our children. These are self-selecting women, because I work very hard to try to take good care of myself. I eat right, I exercise, I don’t smoke or do drugs. I do all of the things that optimize my own health, which optimizes my own pregnancy and optimizes my birth. And so when my second daughter was born, again in her bedroom in the comfort of our home in 2009, all I could do for the first half hour was just to look at her and say, 'no one can take my baby away from me, no one can take my baby away from me.' Because having a baby is not just the removal of a baby from a woman’s body. There are so many emotional aspects to that that create a healthy bond between the mother and the baby, that create vibrant, healthy babies, that create loving, connected families. And those loving, connected families create a better society, a better community, and a better world. So there’s really so much happening at the moment of birth that forms the structure of our families, which goes to form the structure of our communities, that it’s really our responsibility to do the absolute best that we can to hold this process in as much integrity and respect as it deserves. And if you study the normal physiology of birth, you come to see that

childbirth works best in an environment that is characterized by privacy, quiet, darkness, trust, love, surrounded by constant support, and you don’t get any of those things in a hospital. And you get all of them at home. And so I-- again, like everyone up here, there is a time and a place for the hospital for the women who have health challenges, for the babies who have health challenges, and thank God for that. Thank God for their presence and their service. But there are also women like myself, like I said, who take great pains to educate ourselves to take the absolute best care of ourselves that we can so that we can have this. It’s not just because I wanted to give birth in some spa like experience.

CHAIRMAN: Ms. Brown?

BROWN: Yes, sir.

CHAIRMAN: I'm going to have to ask you to conclude please.

BROWN: Yes sir. I absolutely believe that homebirth is a 100-percent safe option when it is planned, when it is trained by a certified and qualified attendant. Women are not going to stop making these choices, but if you vote for this bill you will guarantee that they can continue to make these choices in a manner that is the most safe for themselves and their babies. Thank you.

CHAIRMAN: Thank you. Ms. Corbin?

CORBIN: Thank you Mr. Chairman, Madame Vice Chair, members of the committee. My name is Catherine Corbin. I live with my family on a farm in Carroll County, in Mr. Ready's district. I made the decision to birth at home when I was 28 weeks pregnant. It was not something I made quickly. It was a slow decision over a number of weeks. I was having trouble with my OB/GYN practice. There were four people in the practice; you have to meet with all of them, you never know who’s going to be at your birth. I was not happy. I was not comfortable. I was concerned about the rate of c-section at our local hospital, and I really didn’t feel comfortable driving two hours down here to Annapolis to the local birthing center, particularly since we had a number of snowstorms back in February 2010. [Laughter] I have a half-mile long driveway. I hiked it eight months pregnant, to make sure I could do it. [Laughter] I wanted the safest, most comfortable environment for my child, for my husband, and for myself. I had complete confidence in my midwife. I interviewed. I had two choices to birth at home at that time. Neither of those women are available at this time. I want to have more kids. I want the option to do it safely, and to do it at home, because that’s where I was comfortable, that’s where I was happy. I was in labor twelve hours. I walked the dog, I watched a movie, I cleaned the house. I loved my birth experience. I loved the people around me and I want that option for other women in this state. So please support this bill.

CHAIRMAN: Are there any questions for this panel? Delegate Ready.

DEL. READY: Question for Mrs. Brown, and to my constituent from Carroll County. Yeah, the snowstorms really hampered my sign waving schedule, and so I’m glad to know that we were both similarly inconvenienced. [Laughter] I’m just kidding. [Laughter] Glad you’re here today. You were talking about-- you’ve all, and I’m sure the other witnesses will allude to this--about the impersonal nature of having a birth in a hospital. My wife and I are expecting a baby in May, and we are going to have a baby at a hospital, so you know, one of the things we’re working on right now is our birthing plan. Did you did you have the option of doing a birthing plan? One of the things in the birthing plan is we don’t want the baby taken away. Is that something that is a result of this complaint, or is this something--did you not have that available during your first birth experience.

BROWN: Yes sir I did have a birthing plan, but because part of my birthing plan was to stay at home as long as possible, I literally arrived at the hospital and within five minutes the baby was born.

DEL. READY: Oh, I see.

BROWN: She was healthy weight, she was pink, she was breathing, she was absolutely fine, but I assume just because of the quickness with which it all happened was perhaps why they decided to take her away for observation. It was part of the birthing plan, but again, because we arrived sort of at the last moment, perhaps the nursing staff did not read the birthing plan, and were not prepared for that. I wasn’t even really briefed on why-- you know, I was sort of left in the dark and I just sat there for an hour kind of shaking from the postpartum hormones going, 'where’s my baby?' you know, a little bit confused because it was my first time, my first experience I didn’t really know...

DEL. READY: You don’t always know the right questions to ask when you’re in that situation.

BROWN: Exactly. So it wasn’t part of my birth plan to have the baby taken away, but because of the rapidity with which this all happened, I guess no one either read it, or they didn’t respect it and it happened anyway.

DEL. READY: OK, thank you. Thank you Mr. Chairman.

CHAIRMAN: Delegate Nathan-Pulliam.

DEL. NATHAN-PULLIAM: I would like to thank both my constituents for being so articulate, thank you.

BROWN: Yes, ma'am, thank you.FIELDING: Thank you.

CHAIRMAN: Are there any additional questions? Thank you very much for your time and your testimony here today. We do appreciate it. Let’s bring up Victoria Carp and Robbie Ralph. Good afternoon, thank you for your patience. Who would like to begin?

VICTORIA CARP: Good afternoon I’d just like to take the time to thank Mr. Chairman, Madam Vice

Chair and all the delegates for being here today. My name is Victoria Carp and I’m a student at the University of Maryland. I’m 24 years old and I have never had a child. I’m not pregnant right now, but this is an issue that I feel is really important. I'm 24 years old, and to be honest with you, I’ve done a lot of research around birth. I’m very healthy, and I think that this is just something that is really important. I actually hope to not get pregnant for the next two years, but that doesn’t mean that this needs to be done now. So you know, one of the things-- you’ve heard a lot of stories and so I just want to say, coming from a 24-year-old who is a student, this is something that I hope the delegates--that you will all support and pass. It is really my hope that a homebirth will be a safe and viable option in Maryland. There’s so many reasons why homebirths are safe and viable options, and some of the reasons why I personally want to have a homebirth is because I want to have control over my body and I want to be able to experience things on my own terms. And I think that that’s something that really can’t be done at a hospital because of policies and procedures. At home I will have unlimited options to be able to have natural pain management, so whether that’s putting on music, or going to a bath, or whatever it might be, and I think that that’s something, again, that can’t necessarily happen in a hospital.

Actually, in homebirths there’s a significant decrease in the risk of infection, and it makes sense, because hospitals are really created for individuals who are in emergencies or sick. So if you decrease the likelihood of being in contact with those people, you decrease the likelihood of infection. And last but certainly not least, I decrease the likelihood of having invasive procedures and drugs, which is something that I really don’t want to have during my birth. So really, what I’m asking the delegates today is to support my dream of having a safe homebirth by supporting House Bill 1056, so thank you.

ROBI RAWL: All right thank you Mr. Chairman, Madam Vice Chairman. my name is Robi Rawl. I am also a student at the University of Maryland School of Social Work, but I’m a bit older than Victoria. I had my first child--my first child just turned nine months old, a chubby-cheeked blue-eyed little boy named Charlie. I had him in a hospital, which was familiar to me. Having a midwife didn’t even occur to me until I was about six months along, and that’s fine. I didn’t--I had a very good

experience with a well-refuted practice. But at about the same time, my best friend was also pregnant, and she decided to have a planned homebirth with a midwife. She lives in Virginia, so this was much easier for her to be able to do. So only at that point did I start to become familiar with what was all involved. And you know, other than knowing that midwifery is a centuries-old practice, it’s a tried and true tradition used very frequently by pretty much every other nation in the world, I really didn’t know anything about what it meant, or what it was in this country. I’ve got to say though, when she told me she wanted to have birth at home in her bathtub, I really thought she was a little crazy and that she was exposing her child to unnecessary risk. That the questions are, you know, 'Well, what happens if there is an emergency?' I mean, certainly there’s the plan--if everything goes, you know, as you hope it will, then it’s fine, but is that realistic? And why in this day and age, especially living along this DC Corridor here, and I live in a town where Johns Hopkins is and the University of Maryland, and GBMC is my local hospital. You know, why would I not choose to give birth in a hospital? Why would I risk complications at home?

So she continued to stress that not only was planned homebirth as safe as in the hospital, but she even insinuated that perhaps it was safer. I thought, 'No, this is crazy.' So I being an academic, I looked it up myself, and I used my access to peer reviewed academic journals and I looked at what the World Health Organization had to say, what the CDC had to say, what the British Journal of Obstetrics had to say, and every single one of them showed me that planned homebirths are just as safe as hospital births. Mortality rates are actually significantly lower on planned homebirths with a midwife. One of these reasons it comes into play are the much higher use in hospitals of interventions. So as many people have attested to, c-section rates are higher than 30% in many, many cases. The World Health Organization recommends avoiding unnecessary c-sections and by definition, 30% c-section rate-- you know these are women who are low-risk having healthy pregnancies who are being given this intervention. Cesarean sections, when performed unnecessarily, are dangerous. The CDC, the WHO, the British Journal have all attested to this.

Economically, this is very prudent for our state and for our country. As we look toward the Affordable Healthcare Act being implemented, we know everybody’s budget is tight in the state. You know, you have to deal with whatever O’Malley hands you, right? So births attended by midwives save money on every level. The State of Washington data has been presented already. Healthier babies cost states less in assistance once they are born, so with a higher level of prenatal and postnatal care given by licensed midwives, these births result in fewer low birth weight babies, higher breastfeeding rates and a greatly reduced c-section rate. All of these significantly lower medical costs. So thank you all for your time. As I consider planning the birth of my second child one day when I finish graduate

school, I would really like this to be an option and not have to go to different states as my friends have done in order to have a midwife birth. Thank you.

CHAIRMAN: Very good. Are there any questions for this panel? Thank you very much for your testimony here today. We do appreciate it. Let’s bring up a panel from the department. Fran Phillips, Patricia Noble, Mary Lou Watson. Deputy Secretary Phillips?

DEPUTY SECRETARYFRANPHILLIPS: Thank you Mr. Chair, Madam Vice Chair, members of the committee. Fran

Phillips, the Deputy Secretary for Public Health. And it is a pleasure to come before you and offer the department's support with amendments to House Bill 1056, and to have the opportunity to hear the testimony with you this afternoon. It has been truly, I think, a snapshot from a consumer perspective on how to have babies in Maryland, and certainly there are ways we can improve that. I want to commend the sponsor Delegate Kelly--we did have an opportunity to meet with Delegate Kelly soon after the bill was introduced, and I want to acknowledge our appreciation for the amendments that have come forward and the spirit of those amendments.

To preface my brief testimony, what I do want to say is the context in which the Department approaches this discussion is from a context of what we have been driving down for the last four years and that’s Maryland’s infant mortality rate. And we have made tremendous progress. We won’t declare success yet, but we now have an infant mortality rate that is the lowest that it has ever been. And so in the last three years, 121 fewer babies have died before their first birthday as a result of this concentrated and very focused effort to do many things. So it’s not just one thing, and all of you know that this is in local health departments, the hospitals, the nursing community have been driving down, making sure that women are healthy when they get pregnant, that every pregnancy is an intended pregnancy, and that there’s access to best quality prenatal care, hospital care, and pediatric care thereafter. So that’s the context in which I offer this testimony and look at this issue, which is to say: first do no harm. So in that I am not suggesting that opening up another provider group to deliver babies in Maryland necessarily will cause harm, but it is from a perspective of evidence that we need to make a very, very prudent and deliberative decision about what Maryland does with regard to delivering babies. It goes right to the heart of public health in Maryland, so really what you will see in the Department's amendments are call for a workgroup, and call for a workgroup that really addresses the questions that you have raised to witnesses three areas: One-- should Maryland take a look at licensing this new category of practitioners that would be professional midwives. So what does the evidence say with regard to their outcomes, about which there have been many questions. What are their educational

requirements, what should be their collaborative agreements, what should be their liability conditions, advertising? So what are the parameters that Maryland could safely allow this new provider group to practice. That’s one issue for a workgroup to consider. But I want to come and use this opportunity to raise a second issue, which has to do with not the new group of midwives, but the current group of Certified Nurse Midwives that are currently licensed and practicing in Maryland, and we don’t have enough of them. Director Noble advises that we have 211 licensed nurse-midwives in the state. Two hundred and eleven. We don’t have a nursing school in the state that produces nurse-midwives. Neither Johns Hopkins nor University of Maryland any longer have a training program that produces this class of advanced practice nurses. Why is this important? As it came out in some of the testimony, the practice that nurse-midwives can offer to women goes beyond labor and delivery. These practitioners can offer well-woman care throughout the entire life cycle of a woman, can offer contraception and family planning services. We know right now, today, in parts of the state we have had problems with access to prenatal care because there are not enough obstetricians. Somerset County: no obstetricians . We have problems also with women accessing family planning. It doesn’t take a surgeon to provide a family planning visit, and yet we have difficulties with family planning access.

This legislature last year expanded, through a Medicaid waiver, access to family planning for about 40,000 women. We have real concerns about who are going to be the care providers for these individuals. And lastly, we know that there are pockets of disparities--health disparities-- bad outcomes for women because they have not had the kinds of cancer screenings, well-woman screenings that they need-- cervical cancer, breast cancer--that is again in the scope of practice for nurse-midwives. So the second thing that I would ask that this workgroup do over the course of the summer, to report back to you all next year, is to look at why Maryland is behind the curve relative to what other states are utilizing nurse-midwives to do--the kinds of fundamental well-woman care as well as deliveries that we are not taking advantage of--and why is it we are not producing our own here in Maryland. The third area that I’d like the workgroup to look at is what you heard about home deliveries--homebirths. The Department made a statement last winter about homebirths and it goes like this: 'For the right woman who is screened and is healthy, and has the right competent provider attending her home delivery with the right transfer plan in place should something go wrong, a homebirth can be a safe birth.' So those are three conditions. We are concerned because we know that there are homebirths happening in Maryland that are attended by unlicensed providers. What is driving that? So the third area that I would like to suggest that the workgroup look at is the consumer perspective. Why is there such a concern about unsafe practices in our hospitals? We’d want to include the hospital association on this workgroup. The hospitals need to hear if there are concerns about unnecessary

medical procedures that can result in bad outcomes, can result in unnecessary infections. That’s something that we need to bring forward and to study in a very collaborative way including our hospital partners. We need to have the consumer perspective on this workgroup, and also I would submit that we need to have the perspective of an expert who looks at the health disparities-- whether that is racial ethnic or geographic disparities-- so that we do the right thing for all women in Maryland. So with that I am happy to take any questions and again urge a favorable report with amendments to House Bill 1056. Thank you.

CHAIRMAN: Thank you and the rest of the panel. Now Ms. Noble.

PATRICIA NOBLE: Mr. Chairman, Madam Vice Chair, members of the committee. My name is Pat

Noble. I’m the Executive Director of the Board of Nursing, and I would like to announce at the outset that the Board of Nursing is not the Grinch that stole home deliveries. Just so you know, the Board of Nursing is not opposed to home deliveries. The Board of Nursing is not opposed to midwives, and just on a very short personal bent, one of the premier midwifery schools in the United States was about fifteen miles from where I grew up. And at the point that it started, they went on horseback to do home deliveries, because there weren’t any roads. So I spent my entire life in that kind of environment, and have absolutely no problem with home deliveries or with midwives. What I would say about the Bill right now is that I would support--the Board of Nursing would support the amendments submitted by the Department. We are not supportive of the Registry. Nobody that’s doing hands-on care needs to be left totally unattended with absolutely no oversight, regardless of how short the time period may be. So we would support, with the amendments, and that’s all I have to say but I’ll be happy to answer questions.

CHAIRMAN: Ms. Watson.

MARY LOUWATSON: Thank you Mr. Chairman and members of the committee. I am here as a hospital

representative, so I would be glad to add any information that would give you clarification about hospital performances. Clearly, as a hospital, we cannot afford to have high rates of infections, we cannot have afford to have high rates of complications, or we wouldn’t be in business. We would be closed down, we would lose our licenses, we would lose our regulations. I’m here today as the Chief Nursing Officer of a hospital in Southern Maryland Hospital where we have a 12% Amish community, and we have a significant number of homebirths. We have homebirths that are provided by Certified Nurse Midwives; we have homebirths that have been provided by CPMs. In the years 2008-2010 I became aware of the presence of a CPM in our county. The CPM came to my awareness

because we had a lady arrive in our emergency room who’d been laboring for 40 hours. When the baby was finally delivered by the obstetrician, the baby was delivered in such meconium-stained amniotic fluid that we barely recognized it as amniotic fluid. This woman continued to stay on our radar because of complications in the home deliveries, because her preference was that the home delivery would occur, not that the safe arrival of the baby would occur. We worked with the Amish community and we said, 'If this is what you want to continue, we need to meet with this lady, we need to talk with this lady,' and what I did when I met with this lady is I said, 'Please, identify an obstetrician that you can call when you’re in trouble. Identify an obstetrician that when you’re sending a mother to the hospital you can call and give this obstetrician information of whatever the time period is of labor that you’ve spent, and the obstetrician is prepared to handle the mother in whatever condition she arrives.' The last delivery that we witnessed from this lady was a set of twins. Twins are a complicated delivery from the outset, and both children were troublesome in the delivery process, so the CPM notified EMS and said, 'Please get to this house right away.' . By the time EMS arrived, she had managed to deliver the babies, and one of the twins was in trouble and on the mother’s chest. The CPM directed the EMS team to leave the household, because at that point the baby was getting skin-to-skin and the baby was getting nursed and the CPM evaluated the baby as having come through whatever was that crisis. Four hours later, the CPM is no longer there, and the mother calls 911 again. That baby was flown to Children’s Hospital and the baby is now basically a major consumer of healthcare throughout the state, because this child will have permanent retardation for the rest of his life. Home deliveries are not something I disagree with. I agree with what Fran Phillips laid before you-- the right woman, the right circumstances, a healthy mom-- home deliveries are fine. We have Certified Nurse Midwives delivering babies in our county, and those deliveries are without complications. Those deliveries are deliveries that those ladies have an agreement with an obstetrician. When they get in trouble, they call their obstetrician. I think the issue to answer for yourselves is what is the safest way to do home deliveries? Not whether or not home deliveries should be done. And I would propose that the safest way to do home deliveries is with Certified Nurse Midwives. In closing, I’d like to say that I support the amendment that the DHMH has put forward.

CHAIRMAN: Delegate Huber.

DEL. HUBER: Fran, many times you’ve come before this committee and talked about workgroups in different areas, and I believe you are very sincere in your efforts to doing this. But in my twenty years down here, the health occupations scope of practice that we go through in this committee is more like refereeing a basketball game. You have to put on a black-and-white striped shirt, take out a whistle and blow every twenty minutes, because you’ve got doctors and nurse, practitioners going against each other, you’ve got anesthesiologists and nurse

anesthetists. And I’ve come to realize in twenty years, it’s not about the scope of practice, it’s about the money. It’s about the economics of this issue, in reference to who can put whom out of business. So I’m suggesting when you do this workgroup, that the politic involving this workgroup better be neutral, because the best way to kill this whole issue is to have a workgroup stacked up with hospital representatives and nurse practitioner representatives and very few midwives. And I think there needs to be a couple other people, including some elected officials on this as well, to make sure they have the referee and the referee shirt and their whistle at these workgroup meetings. [Laughter]

PHILLIPS: Thank you Delegate Huber, I appreciate any suggestions that you would have as far as the composition of the workgroup. I know that it's a tall order for a scope for this workgroup, but I also see that there’s an opportunity for that sweet spot that’s the triple aim. The triple aim in healthcare is to do three things: one is to improve the patient’s experience with healthcare; the second is to improve the quality outcome of healthcare; and the third is to reduce the cost. And there very well may be, with this opportunity, to look at how we manage delivering babies in our state that triple aim can be achieved. It’s not easy but it’s certainly something that a multidisciplinary group could address.

DEL. HUBER: Yeah, and the last issue, number four, Fran, could be the fact that we have lower infant mortality. And the issue here is, if it’s safe and we can do it and we can provide broader and better access and we’d have lower infant mortality, there’s no reason why we shouldn’t.

PHILLIPS: Thank you. I appreciate that, Delegate.

CHAIRMAN: Delegate Costa.

DEL. COSTA: Thank you Mr. Chair. Fran, let me ask you: is access to healthcare a priority for the Department of Health and Mental Hygiene?

PHILLIPS: Yes, absolutely.

DEL.COSTA: If you recall a couple years ago, there was a task force on access to healthcare and physician reimbursement do you remember that task force?

PHILLIPS: I wasn’t as closely involved in it perhaps as you were but I do recall that.

DEL. COSTA: My seat mate next to me and I were both on that for nearly two years, and we studied this issue of access to healthcare. One of the things that came out of it was the significant unavailability of OB/GYNs throughout the state, primarily in southern Maryland-western Maryland and the Eastern Shore. Do you recall that in the final report?

PHILLIPS: Yes I do.DEL. COSTA: It actually said that the average age of an OB/GYN in those districts was 66 years

of age. Now do you think that these midwives would be a tremendous support opportunity to increase the amount of access to healthcare in these vital regions of the state?

PHILLIPS: Thank you Delegate Costa, and I think that’s exactly what this workgroup needs to look at. So we as a state, Maryland does not fully use the model that other states do for midwives. Not only for deliveries of babies, but for other kinds of healthcare issues for women. It is an opportunity to do--not just work force issues on liability questions, but as we look at the advent of health reform-- when more people, more women, will receive health insurance what is going to be the workforce there to take care of them? So unless we fully use people up to their skills, their competency, and their education, we’re cheating ourselves and we’re cheating patients. So that’s absolutely part of what I think we need to do. As far as the distribution of OBs, it’s not what it should be but we can do better.

DEL. COSTA: So do you believe that in the end, the focus of the workgroup should be to make sure that we provide every opportunity to provide access to our constituents by the use of midwives?

PHILLIPS: Yes, and I believe that the focus of the workgroup should look at this new group of providers, this professional midwife group. Look at their potential to contribute, and also look at the existing licensed nurse-midwives. Look at the supply, look at the distribution and see what we can do to prompt more of access.

DEL. COSTA: Thank you.

PHILLIPS: Thank you. CHAIRMAN: Delegate Nathan-Pulliam.

DEL. NATHAN-PULLIAM: My question is a little bit different. I just wanted to know--and I should have

asked the nurse-midwives-- not the nurse-midwife, was there any midwife that testified before? But the question that I wanted to ask, when they do a homebirth, who does the PKU and the bilirubin and sickle cell tests and those things that are done usually within--some are done, like PKU is done, right after birth?

PHILLIPS: So the routine newborn screening?

DEL. NATHAN-PULLIAM: Yes the routine newborn tests.PHILLIPS: That’s sent to the state lab. That is done through homebirths by the nurse-

midwife, does that collection and sends that to the lab, or it can be done 24 or 48 hours later by the pediatrician. It is a good question, because that is exactly to the part of what is routinely required--not even in emergency situations with regard to delivery--but what are the routine expectations for a normal delivery, and how best to provide that in a homebirth setting.

DEL. NATHAN-PULLIAM: Okay, so the CPMs and the Certified Nurse Midwives, I see them shaking their

heads. Obviously they do those tests as well.

PHILLIPS: Correct.

DEL. NATHAN-PULLIAM: Okay, thank you very much, I just wanted some clarification. And that goes also

for circumcisions. Who does them?

PHILLIPS: I can’t speak to circumcision.

DEL. NATHAN-PULLIAM: They go to the pediatrician.

PHILLIPS: Don’t know that, I’m sorry.

WATSON: Usually pediatricians do them. [murmuring & background noise]

NOBLE: Pediatricians do them.

DEL. NATHAN-PULLIAM: They’re not required. Well, it’s not a requirement, but most hospitals do them

right after.

CHAIRMAN: Delegate Kipke, then Delegate Krebs.

DEL. KIPKE: Thank you Mr. Chairman. Good afternoon, thanks for being here. A couple of quick questions. One--I guess this would be best answered by the Board--do licensed nurse-midwives have training at homebirths?

NOBLE: It depends on the program they’re in. They have--their agreement that they have allows or does not allow for home deliveries, and that’s based on how they’re trained and their collaborator.

DEL. KIPKE: Okay, because one of the things I heard earlier was that some have tried to establish programs, and they’re having problems getting the programs established. And then there’s also a great demand for homebirths so there seems to be a roadblock still. So I’m trying to understand maybe you can explain it. Are they not trained in homebirths?

NOBLE: Well, some of them are, some of them are not.

DEL. KIPKE: Okay, and then Fran... NOBLE: A normal delivery …

DEL. KIPKE: A question for you is, in determining this, have you looked--you know, the past month this was on my radar, I’ve been trying to look at scientific data about this, and I’ve learned that most of Europe does it as a regular thing, south of our border, and then I looked at the United States and it’s a growing-- 26 states currently have it, Virginia, New Jersey, Delaware, and so I hear resistance, perhaps, from you in your testimony and I’m curious; what studies can you cite that you looked at in determining your testimony and your position for this?

PHILLIPS: Delegate, I want to be clear-- I’m not expressing resistance, I’m expressing resistance in going forward without looking at the evidence, and doing so in a collaborative way. So it is not possible for me, I haven’t done the background--the homework that you’ve done, clearly, as far as what the other states' evidence has been, and what the other countries-- and I know that that’s something that’s available to us that we need to study. So it is not resistance, not coming into a workgroup with a preconceived idea, but it’s clearly one to say this would be a major shift in how the state regulates and how the state licenses a new class of providers, and that’s something that needs to take some collaboration. Not only with the outcomes, as I mentioned, but also, how will this group integrate with other providers-- the handoff to the lab, to pharmacists, to hospitals, to other physicians, to social workers, to addictions counselors. How is that going to be integrated into care? That takes some time.

DEL. KIPKE: And last question, Mr. Chairman, to the lady in the middle, I’m sorry, can you tell me your name again?

WATSON: Watson.

DEL. KIPKE: Ms. Watson, can you tell me who you represent? I’ve never seen you before, so…

WATSON: I am the Chief Nursing Officer at St. Mary's Hospital and I’m a member of the nursing board.

DEL. KIPKE: Okay and you raised--you shared with us a story, an alarming story, and if Fran didn’t raise concerns, you certainly did with your story.

WATSON: [Affirmative]

DEL. KIPKE: Correct? Was that the purpose of your testimony?

WATSON: [Affirmative]

DEL. KIPKE: This story that you shared-- is it something that is documented, either through the media--because, you know, basically your story is sort of hearsay because I have no reason to believe you or not believe you. Is this something that I can fact check?

WATSON: It absolutely is. You could start with the hospital itself, because we’ve got the documentation at the hospital; however, there were several letters that were written, because as we tried to-- I mentioned that we first tried to work with this CPM to get her to identify a physician to collaborate with, which she did not do.

DEL. KIPKE: Say that again?

WATSON: We tried to get the CPM...

DEL.KIPKE: When?

WATSON: During the period of time, 2008-2010, when we were working--when she was in our community, we tried to get her to collaborate with a physician, and she did not do that.

DEL. KIPKE: And that’s prior to this incident, this alarming...

WATSON: With the twins, it’s prior to the incident with the twins.

DEL. KIPKE: So prior, you tried to get her to do something.

WATSON: Right, because the very first time I became aware of her we’d already had this prolonged labor with meconium stain in the amniotic fluid, which is potential for significant morbidity, so...

DEL. KIPKE: And how personally involved...

WATSON: ...so that’s not insignificant.

DEL. KIPKE: How personally involved were you in attempting to get her to-- with her?WATSON: I met with her and with the Amish population, because...

DEL. KIPKE: Personally?

WATSON: [nods] The Amish population were interested in maintaining her services. So I met with them, and I said, 'what we need here, is instead of these women arriving at the emergency room with nobody knowing what’s going on, and then finding out from the patient, if we can, what happened to the patient, it was important for that CPM to be able to give a sign-off report or a hand-off report to the physician to say 'here’s what I’ve been doing for the last 40 hours.''

DEL. KIPKE: But a lot of the testimony that I’ve heard about licensing these folks would clear that up and create a pathway for that. Would you agree with that?

WATSON: There needs to be an oversight body whatever happens, but I think you still want a level of quality care, and that level of quality care is best achieved through adequate training and adequate education. And I still go back to-- I think your bare minimum is the Certified Nurse Midwife.

DEL. KIPKE: And will you just--because I want to do a little research about the story that you shared, because, you know, I’m going to vote on something that will have a dramatic public health impact.

WATSON: This lady went over to the State of Virginia and assisted in a delivery in Virginia, and the baby died.

DEL. KIPKE: I didn’t ask a question, hang on a second please.

WATSON: Okay, I just wanted to finish your earlier comment, sorry.

DEL. KIPKE: OK I’d like to will you just restate on the record that everything that you said is accurate and honest and reflects the case that you shared with us.

WATSON: I absolutely will say that, and that information is available upon request.

DEL. KIPKE: Thank you very much. I’d like to request it now, so can you-- I don’t mean you have to present it at this moment magically. I don’t mean to startle you, but I’d like that information. How soon can we have that?

WATSON: I will forward it to Pat Noble, and Pat Noble will get it to you.

DEL. KIPKE: Thank you very much. Thank you, Mr. Chairman.

CHAIRMAN: Delegate Krebs.

DEL. KREBS: Thank you, Mr. Chair. I want to echo what Delegate Huber said about these workgroups, and I’m pleased you’re looking at a workgroup, but I’ve been involved in these workgroups before and you have too. They’re a little frustrating, and sometimes they do come with preconceived outcomes. I just want to ask you a couple things that I want to make sure happen if we move in the direction of this workgroup. I know that already sitting here we’ve got preconceived notions that we need to do CNMs, and that we need to control this, and restrict it, and I want to make sure that part of this workgroup is looking at giving people choice. One of the most basic thing you do in your life is to give birth to a child. I mean, I remember last year we had a discussion about whether we could drink milk from a cow, that we regulate that. You know, we can’t even drink real milk anymore, because the State tells us it’s not safe, and that sort of drove me nuts and you know that, but I’m going off subject. [Laughter] But it’s sort of related, Mr. Chair. My point is, this is a basic choice that people make, and there’s no evidence--I haven’t seen evidence--and that’s what I’d ask you to look for. Not anecdotal evidence; you can give a story about this issue, you can get ten stories about a hospital, so we can get up here forever and give story after story after story, and that’s not data. I would like you to look at these other states and other countries, and use like data, and say, 'We’re asking people to give up a choice of giving birth at home. I mean, our founding fathers would have a heart attack to think we’re even having this discussion, that the state regulates where you have to do it and with whom. But I’m hoping that we go into it with an open mind, and not just--and it should be about access to care, and it should be about least regulation possible. And it should be about giving people choices, and these are educated people. These aren’t people making this decision fly-by- night to do this, I mean, I think it’s a pretty incredible decision to do this.

I have testimony in the file-- we all do--of people, I don’t know if they’re coming behind this, that are all opposed to this. And they all--it's the same old thing as Delegate Huber said-- they have their little niche, and I want to make sure that this group that you put together is going to really-- our goal, I think if you get the feel from the committee, our goal is to make something happen in a safe way as quickly as possible. And I want to make sure that is going to be the goal of the committee and we’re not going to just waste another year and come back here and say, 'Oh everybody’s got to be a CNM and go to school forever to do this.' How can we be assured that the purpose of this is to find--get the bugs out of where we’re trying to end up? I think--I don’t know, I get the feel from the committee we’re trying to end up to make it be more accessible, more choice.

PHILLIPS: So if I could address a couple of thoughts here. Thank you Delegate Krebs, because a part of what you’re raising is who’s the composition of-- knowing that this is a complicated area, the composition of the workgroup; how are we going to get it balanced so that we get to the right answer, whatever that may be. You know, if you think about it, we’re all after the same thing. We’re after an improved experience, we’re after safety, and we’re after lower cost. And so if there are suggestions to add to the workgroup, where you think that there will be some hard-hitting analytical, critical thinkers, who will be looking at where can we maximize safety, improve outcomes at the lowest cost, that would be a contribution to the workgroup that I think would get us to the right place. So I guess I’m thinking about payers, I’m thinking about who best to look at how can we assure the present level of safety, and yet look at some alternative providers and alternative care settings. Now, the state is not now, and has no intention of, outlawing, banning, regulating homebirths. That's not happening, but what you do hear correctly is that the supply of providers, the provider mix in this state, is such that there is an insufficient capacity right now of licensed nurse-midwives to meet the demand for homebirths. That’s a fact, we know that that’s a fact. And so the question that this workgroup has to look at is, what’s driving the demand for homebirths and how could we step up the providers that will provide homebirths to the right patient in the right setting at the right time.

DEL. KREBS: Well that’s what I’m getting to. That’s what I think the goal is. How do we provide more access for people that want to do this, and give them choice without adding layers and layers of

PHILLIPS: I don’t think any of us disagree with you on that.

DEL. KREBS: Well, that’s our goal.

PHILLIPS: Completely, right.

DEL. KREBS: ...and I would love to participate, or let us all know about-- I think the American Association of Birth Centers, I don’t know if they’re in the legislation-- this document they gave us has got a lot of very good information in it, but use the people that are already there and the information, and look, please look outside of our country and outside of our state. We’re not reinventing the wheel here, we’re sort of followers. I mean, we’re basically going back a hundred years and just letting people do what they did for centuries. I appreciate that we’re not going to get into more regulation and filling this with doctors and all that are going to put limits on it. People have those choices, if they want to go to a hospital and go to doctors, and most people choose that, and that’s wonderful, but these people want a different choice.

PHILLIPS: I understand.

DEL. KREBS: Thank you.CHAIRMAN: Okay, let’s hear from the sponsor of the bill, Delegate Kelly, then Delegate

Cullison.

DEL. KELLY: Thank you very much Mr. Chair. I have a lot of questions, but I will try and just start with the most important one to me. First of all I want to thank you, you all have been very helpful in working towards a solution that we can possibly come to in order to help the folks here who really, really deserve this as an option and a safe option, so thank you for that. On your amendments, I did send you some-- my proposed amendments, which were similar, in that they called for a workgroup. But it was a workgroup with very different people in it, to sort of get around the issue that I think several of my colleagues have addressed. You know, it’s not my opinion that the workgroup should contain all of the people that have a financial interest in making sure that Certified Professional Midwives don’t have access to help people. [applause]

CHAIRMAN: Excuse me ladies and gentlemen, we can’t do that, okay?

DEL. KELLY: But you know, most importantly to me, and I mentioned this when I introduced the bill--and I think my colleague Delegate Krebs actually mentioned this as well--we have resources available to us to answer the questions that are important to the Department on the public health issues. There are I think--and if you could speak to this, I would really appreciate it-- it is my understanding that there is basically an underground network of people who are doing this work right now in the state. We know that they are doing it. It is my understanding that they are deeply concerned and afraid that the Board of Nursing is going to basically charge them with practicing nursing without a license under the existing law, and that that is why we have so many complications that are unnecessary. And I think that we need to get to the crux of that problem with this workgroup. If we have the Certified Professional Midwives, and other midwives who may not be qualified or certified, all delivering services for these consumers, it’s very confusing and dangerous for consumers. And the folks who can be very easily and effectively integrated--if we come up with the right system to do it-- into our larger healthcare system, increasing access to providers, providing quality care, we need those people to be able to come to the table at the workgroup, and I don’t see any way we can do that without addressing the fact that there is currently a ban on the books. And they’re terrified that if they come out of the woodwork, they will be charged with practicing nursing without a license. Can you help me with that in terms of how--

NOBLE: Well I can try. First of all, I believe we have some of them here today, and I did not call the police to come and do anything about it before I came here today. I’ve met with you, we have discussed that. I have tried to make it perfectly clear, and I must not have, that the Board of Nursing is very willing to work with this. I do not believe that there is a history of the Board of Nursing going on a witch hunt after these individuals. I don’t see that there’s any evidence to support the fear. I also recognize that fear of the unknown is a horrible thing, it truly is, for anybody in any kind of situation, but we are obligated statutorially to protect the public on the one hand; on the other hand, we’re trying to work this out. The board has no intentions of doing anything. If we get a complaint, we have to deal with that. We don’t have any authority to discipline these people; they’re not under the auspices of the Board of Nursing.

DEL. KELLY: So when we last talked, you had suggested that maybe you could talk with your folks to come up with some language that would help us. I think you used the term “hold harmless” the Certified Professional Midwives during the time in which we are figuring out a system that would work. Is there anything you could offer on that?

NOBLE: Historically what has happened, I think, with all the boards, but I’ll speak just for the Board of Nursing, complaints are confidential for the most part. We all have --well' all' may not be right--we have a compelling purpose written into our law. This doesn’t fall under that. What I can do, is to tell you that if we get a complaint, I’m under no obligation at all to keep a complaint of this nature-- if we don’t deal with them and they’re not under the Board of Nursing--to keep that confidential. I am more than willing to share that with you. I’m more than willing to talk to you about it, I am more than willing to talk to them about it. Beyond that there isn’t anything, because there isn’t anything I have control of beyond that. We the Board of Nursing cannot discipline anyone who does not fall under the purview of the Board of Nursing.]

DEL. KELLY: So, I guess maybe this is actually a more appropriate question directed to Fran then. I mean obviously, there's a court case that’s referred to in our code-- I think it’s the Hunter case, right, it’s what all of this is sort of rooted in--that there was a midwife and she was charged with practicing nursing without a license, and there have been other, I mean many, many anecdotal stories that I have heard that contributed to this fear. It is my understanding the Department definitely defended that in the Hunter case. And so I’m wondering if there’s something--I see that you are trying here, and I really want us to get to a place where we can have a productive workgroup with a positive outcome for these parents, but I don’t see that happening unless we can come to some sort of agreement as to whether the Department is flexible on what has been-- you’ve been pretty inflexible on, and I think your amendments show an inflexibility on, in terms of whether the only appropriate midwife is also a nurse.

PHILLIPS: So our amendments call for a workgroup, and it’s not the spirit of those amendments--the intent and the language of those amendments is not meant to be inflexible, and so if there are additions to that workgroup, if there are changes to the scope of that workgroup that you want to propose, absolutely we’d be happy to talk with you about that. As has been commented before, it’s, it’s good to get information but anecdotal information is less reliable than peer- reviewed evidence where you’ve got data. And so we definitely want to have representatives from other states where professional midwives are practicing, are licensed as we heard witnesses here, to contribute input to that workgroup. Now the question of, can the Department host a registry for individuals, as I think your--Delegate Kelly your amendments put forth--puts the Department in a very odd position. A registry for individuals who are not licensed, so it would not be under the Board of Nursing, but a registry of individuals who are practicing a practice that is not licensed. Not to put a pun on the expression 'a little bit pregnant,' but right now in 2012, you either are licensed or you aren’t licensed as a midwife. That’s the circumstance that we find ourselves in. You’re not a little bit licensed, like you’re not a little bit pregnant. So the reality is that this workgroup is a sincere effort to look at who and under what circumstances should be licensed to deliver babies, and as a result of that to make recommendations back to the legislature next year about what changes should be made in the Nurse Practice Act. So I think that what we want is, we want input from the professional nurse community. Anecdotal input is okay, but data, and that’s really available. I know it’s available and we know that there are other states and other countries that can provide that information. We’d be more than happy to work with you.

DEL. KELLY: Thank you for that and I appreciate that. I think to just sort of to sum it up, it’s my hope that during the time of the workgroup, as we’ve clearly shown with our panels, and a lot of the discussion around this issue, this is going on. It’s not going to not go on, complaints filed with the nursing board aside. I’m not trying to bring that in-- I would like to feel a sense of goodwill from the Department in terms of particularly the very narrow part of the Nurse Practice Act that refers to this court case that determined that the legislative intent originally was to make sure that you could only be a midwife if you were a nurse. My hope is that the people who are currently helping women having homebirths right now will not leave this room fearing a witch hunt. I think someone said the intent is not to have a witch hunt I want to make sure that we can alleviate some of that pressure from folks, so that we can have a productive workgroup looking at facts and data and all of the things that you all need to do from a public health perspective. Can you give me any confidence in that?

NOBLE: Other than to tell you that we’ve not done that, there’s no evidence to support that, I don’t know what else to say. I’m willing to come to the table. I have been

willing to meet with you, I have been willing to meet with other members of the committee.

DEL. KELLY: I’m sorry, actually this wasn't related to the nursing board at all. That’s why I meant to say aside from the nursing board, this was directed to the Department.

NOBLE: Okay.

DEL. KELLY: I know you have your statement on homebirth, I know we have to look at the data we have to figure out how to do this in a way that’s safe and productive and in the best interest of the public health. I understand all of that; we have a lot of agreement there. I think the only place that we have disagreement is, how do we deal with the situation on the ground right now with the women who are currently pregnant and the midwives who are currently helping them. That’s my concern as we move forward with addressing this in a thoughtful, slow process of looking at the data and figuring out the best way to deal with this.

PHILLIPS: So the Department is interested in a workgroup that gets input from that. The Department does not enforce the scope of nursing practice. The Department, looking out for public health, makes recommendations. And certainly you’ve heard from the Executive Director of the Board of Nursing with regard to the board’s intent with this workgroup, and I think it’s a very sincere intent to look collaboratively at what can be done to improve the Nurse Practice Act today in Maryland. So beyond that, I’m not sure what other assurances the Department can give you, other than that we will have a sincere and full-throttled effort to look at what is the best course for Maryland.

DEL. KELLY: And that effort would include the midwives who are already doing this and their patients?

PHILLIPS: The Department would have absolutely no objection to having a professional midwife, wherever he or she practices, to be on that panel. The Department does not have an objection to getting input from individuals who have a perspective on professional midwives.

DEL. KELLY: But how can they come to the table if they know they…

WATSON: Nor does the Board.

PHILLIPS: And nor does the Board.

DEL. KELLY: I want them to feel safe coming to the table knowing that they are breaking the law right now. That’s difficult, right? How do we make that work?

PHILLIPS: You know the Department doesn’t enforce that law. The Board of Nursing enforces the law. You’ve heard from the Executive Director of the Board of Nursing, I don’t know what else we can offer.

DEL. KELLY: Okay, well...

NOBLE: The only thing that we ever get involved with is a complaint concerning a bad outcome. And I can’t do anything with the complaint once I get it. I have no authority to do anything with that. We are not looking at people who are practicing. I know they practice. I’ve known for a long time they practice; so does the Board. We have made no effort to charge anyone, to even talk to anyone, much less charge them. And I don’t think that’s going to change. That is what it is, and there’s been no effort to do anything and there's not going to be an effort to do that now.

DEL. KELLY: I think I heard--and again I may have misinterpreted this, so I’m not meaning to plant ideas--but I heard at one point, perhaps you said to me that it’s difficult to get--that you were trying to get people to prosecute folks, that you were having difficulty getting the counties or someone to comply with that.

NOBLE: A states’ attorney..

DEL. KELLY: State’s attorney.

NOBLE: ..in the case of a very bad outcome, and that did not happen. And that was once. I’ve been at the Board of Nursing since 2001. That's once.

DEL. KELLY: Okay, thank you.

DEL. KELLY: And then we know of the 1994 in the Hunter case of course, in reference to the code.

WATSON: Yes, that was before my time.

DEL. KELLY: Sure. Thank you, thank you very much and I really do--I thank you for your support for your attempts to come together on this. I think we all agree that best outcomes for women and children are what we want, so thank you for that. I hope we can work out the details on this.

CHAIRMAN: Delegate Culllison and Delegate Pena-Melnyk.

DEL.

CULLISON: Thank you Mr. Chair. Thank you all for coming today. First, I have to say this is just my second session here in Annapolis, and we’ve dealt with some pretty weighty issues in the two sessions I’ve been here. But I have never received so much passionate, heart-felt mail as I have about this issue and pictures of beautiful babies and mothers and fathers telling me how important this experience was to them. So I have literally hundreds of pieces of evidence that tell me that this is the right thing to do for these people. Certainly there are going to be incidences where there is a bad outcome. There are bad outcomes in hospitals so, you know, I'm sorry for that. I’m sorry for the families where that happens, but I think we need to keep these things in perspective. So, given that little diatribe--what I heard you say, Ms. Noble, just now, if I don’t hear any real objection to sort of making a period of 'hold harmless,' since what you are saying to me-- what I heard you say is that’s essentially what we’re doing now. So if this legislation says, 'We hold these practicing midwives harmless while we convene this workgroup," is there--what’s the issue with that, since that’s essentially what we’re doing?

NOBLE: The Board of Nursing does not have the authority to set aside the law. The law currently says you cannot practice midwifery unless you’re a nurse. I can’t do anything about that. I can tell you again that the Board has made no effort to get out and look for that.

DEL.CULLISON: So if we say in this law that we’re ok with this for this period of time, you all are

ok with that?

NOBLE: You all write the law, I try to enforce it so that’s where we are [laughter].

DEL.CULLISON: OK; is it Dr. Phillips?

PHILLIPS: No.

DEL. CULLISON: Ms. Phillips?

PHILLIPS: I’m a nurse.

DEL. CULLISON: Nurse? Oh, well but you could--I learned about doctor-nurses. Okay, so I’m

looking at your list of people on the workgroup, and I’m looking at Delegate Kelly’s list. And Delegate Kelly’s list is really about--as I read it, some of the people are DHMH, Board of Nursing, Board of Physicians, [Maryland] Families for Safe Birth, North American Registry of Midwives, Association of Independent Maryland Midwives. That’s who’s on her workgroup. That workgroup seems to

me to be the workgroup that’s saying, 'We want to look at the safety and viability and reliability of homebirths using professional midwives.' That’s what that group says to me. Then I’ve got on your list: DHMH, Board of Nursing, Board of Physicians, Board of Pharmacists, Board of Nurse-Midwives, which I don’t think was on Delegate Kelly’s list; the American College of Obstetricians and Gynecologists, The American Academy of Pediatrics, the Hospital Association, the John’s Hopkins School of Nursing, someone who is an expert in minority disparities, a representative of the [Maryland] Families for Safe Birth-- same-- the Registry of Midwives, and the Association of Birth Centers, and any other individual or entity with an interest or expertise in midwifery as determined appropriate by the secretary. So this group seems more like, 'how do we determine safe birth options in general.' It’s not about certified midwives. So I guess I’m seeing two very different workgroups as I look at these two amendments.

PHILLIPS: Thank you Delegate, so they are, they are different. And as I tried to make clear in my testimony, the workgroup that we have envisioned is to cover three objectives; the first objective being in concert to look at this new entity to look at professional midwives and to look at the possibility of licensing professional midwives in Maryland. That’s number one. Number two; to look at why it is that we don’t have--we are not training nurse-midwives through John’s Hopkins School of Nursing stopped doing it, or they do it and they train them in West Virginia at Shenandoah. University of Maryland School of Nursing stopped their midwifery training program. So the second objective of this workgroup, which would then make the workgroup membership broader, is to look at nurse midwives who are advanced practice nurses--have master’s degrees in nursing --but we don’t have enough of them, and we’re not using them to do cancer screening, to do family planning and a lot of other things. The third area is to look at this issue of homebirth; what’s going on in our hospitals that some people don’t feel it’s safe, including Delegate Morhaim, to feel that it’s safer to have a baby at home rather than a Maryland hospital. We need to look at that to see if there are if there are invasive procedures, if there are unnecessary technologies, if there is a culture that is not welcoming. So the idea of the workgroup is to do three things, and therefore it’s a broader group.

DEL. CULLISON: And I don’t disagree there’s a need for that group, but I do think it’s a separate

group and I think we need--this bill is dealing with the issue at hand, which is, we have families who want homebirths, who are actually opting for homebirths, and right now the situation isn’t really--as our laws are written, they’re not conducive to that. So while I think--and I absolutely support what the description of the group that’s going to deal with those three different issues-- I think we need, for purposes of this bill, one that is going to deal specifically with that one issue. Thank you.

PHILLIPS: Thank you.

CHAIRMAN: Delegate Ready.DEL. READY: Not to belabor the point, but I just want to add a couple questions or

comments. I just hear the term 'new entity' and 'it’s a new entity,' and 'we haven’t actually called the police,' and it’s just sort of funny to me. I mean, it’s not really a new entity; I guess professional midwifery is new, but it’s been going on for a long time. To me, it’s basically a consumer choice, and we ought to encourage more choice and availability in healthcare rather than less, in my view. Obviously the State has a vested interest to be sure that we don’t have large numbers of women showing up in emergency rooms, which is very expensive and obviously not good outcomes when that happens. I guess for me, my question would be is there a way that we could--and I know I am sort of repeating questions I have already asked, but I thought I’d try in a different wording. Is there a way we could decriminalize the choice, because basically what we have done is, we don’t enforce it maybe, but it’s, I assume-- is it criminal for someone to practice midwifery in Maryland right now if they are not a nurse?

NOBLE: Yes it is.

DEL. READY: Okay, so what I am wondering is if there is a way for us to--maybe there is a compromise on the workgroup that can be held where we have a mixture of the two different lists, and is there a way we can decriminalize the choice in some way? Because basically, the only way you are going to make-- what I wrote down here is, the only way you're going to make it safe for people to have homebirths-- let’s assume for a moment it’s not as safe to do it as it is at the hospital. Let ‘s adopt the argument that I am sure we’ll hear from some other opposition. If it’s not as safe to do it at home, the only way you are going to make it safe is if you make it and bring in the sunshine and make it legal, because people are going to do it whether you--I guess my question is there any way--I'm hoping – I am making a statement, I guess I'm not really asking a question. I am hoping we can make it so that we can decriminalize it, or find a way to have a list of people, 'These are people who know what they are doing and they are safe,' so that we can--while we are trying to figure out what to do. Is there any way we can get an agreement on that, or that’s my hope I guess.

NOBLE: I don’t think that the Board of Nursing has the authority to throw out the law; however, your point, I believe of 'can we work to that,' that’s the whole point of why we are even here.

DEL. READY: Right, okay.

NOBLE: And the Board of Nursing is absolutely willing to try to work to resolve that.

DEL. READY: Okay, I just...

NOBLE: And I believe the Department is in the same boat.

DEL. READY: Okay, Okay, all right. Thank you very much.

CHAIRMAN: Delegate Reznick.

DEL. REZNICK: Mr. Chairman, Ms. Watson, I think a couple of people had alluded to this, but I want to go ahead and ask it. You have given us a pretty horrific example of a situation where a midwife delivered a child that went horribly wrong and ended in tragedy. But let’s be honest, there have been plenty of deliveries in hospitals with obstetricians and nurses and every piece of equipment known to man, and yet the delivery still went wrong. Developmental and physical disabilities still occurred, death still occurred. Your one example doesn’t negate anything really, does it?

WATSON: What I was trying to drive the point home on, is I had experience that was a counterbalance to earlier testimony.

DEL. REZNICK: And so what I am asking is, have you also had experience with that the same situation or incredibly similar situation happen at St. Mary’s Hospital?

WATSON: I think what’s important to understand there is that when it happens in the home...

DEL. REZNICK: You’re not going to answer the question are you?

WATSON: I am going to answer the question I promise. When it happens at home, you don’t have the backup options to give it its best shot at recovery. In the hospital if something goes south, you’ve got those backup options. They don’t always work, but you got them.

DEL. REZNICK: But the problem still happens.

WATSON: And sometimes the problems are recovered. They don’t always go south and stay south. Sometimes they are recovered.

DEL. REZNICK: The other question I have for you is a much more general one. We've heard a statistic here today that’s a little disturbing and frankly become a lot more reticent on my radar screen. 40% of hospital births are now by cesarean section?

WATSON: At St. Mary’s Hospital it’s 24.

DEL. REZNICK: 24 percent. That has increased over--has that increase been the same over the last ten, twenty years?

WATSON: It’s been pretty steady at about 33 [percent] as the national average--is what the national average is.

DEL. REZNICK: Over what period of time?

WATSON: Many years. I don’t know when it began, but it has been pretty constant at 33. And the issue around c-sections is sometimes babies present breech; there is no option. You can’t always flip those babies; they have to be sectioned. There are babies whose heart rates have fallen too low. You’ve got to get those babies out faster than what you can do waiting for Mom to be able to push them.

DEL. REZNICK: What percentage--if you know, what percentage of deliveries are breech? Are they 33%?

WATSON: No, no, because there are other complications, like I mentioned, if the baby’s heart rate drops...

DEL. REZNICK: So is every cesarean done as a result of a complication, whether it’s breech or other issues?

WATSON: Cesareans can sometimes be elected. There actually is a population out there

that is suggesting that cesareans are healthier births than vaginal births. [Laughter from audience) so you actually do have - I am sorry, but that is actually in the literature; so I am just sharing with you the literature. So there actually is a population who has that research done to show that they are actually healthier if they are delivered by cesarean. And there are moms who elect to have cesareans. Moms who are first time cesarean and have a second pregnancy, are given the option: do you want to have a cesarean or do you want to deliver naturally. Many moms choose to have a second cesarean.

DEL. REZNICK: Cause I’ve heard that if there are issues, if you have a cesarean the first time, you try to deliver the second time, it doesn’t always work out so well. You have to pretty much have to have a second cesarean.

WATSON: It's greater risk.

DEL. REZNICK: Greater risk.

WATSON: There's greater risk.

DEL. REZNICK: Okay. It just seems based on testimony heard from proponents of this bill, and really on what you are telling me now, it seems like there is a lot of unnecessary c-sections going on and I am trying to figure out why the increase. It's costlier... Is…

WATSON: I would be remiss to have given you that impression. I do not believe there a lot of unnecessary c-sections. Are there some? Probably. Are there a lot? I do not believe that.

DEL. REZNICK: Well, maybe we have a different definition of unnecessary. I think elective is unnecessary.

WATSON: Oh, but a mom who decides, 'I don’t want to take a risk with my second pregnancy when I have a first time cesarean section,' that’s elective.

DEL. REZNICK: Okay so we are talking about choice for how you deliver.

WATSON: Right.

DEL. REZNICK: Whether it be cesarean in the hospital or homebirth, or everything in between.

WATSON: I am sorry I didn’t convey that more strongly. I thought I started off with – I am not in disagreement. I am talking here as a hospital person. I am not in disagreement with home deliveries. I think home deliveries, under the right circumstances, with the right patient are absolutely wonderful option. I just think that we have to look carefully at what is the provider qualifications for doing that home delivery.

DEL. REZNICK: Let me ask you this question Ms. Noble. How many nurse-midwives do we have in the state?

NOBLE: 211.

DEL. REZNICK: And how many are certified for home delivery?

NOBLE: I believe the last time I looked, there were 10 who had practice agreements that requested home deliveries. They request--when they fill out their paperwork, they request whether or not they want to have home deliveries, and the docs that they work with are in agreement with that.

DEL. REZNICK: So we have 10 people in the state of Maryland – a state of almost six million people-- who are certified to do home deliveries.

NOBLE: Who have requested that. That is correct. The other ones could do it if they found a collaborator that wanted to work with them or if they were interested, and I think it’s probably a combination of both. There may be an issue with the docs, and they don’t want to do it.

DEL. REZNICK: Okay, well, allow me to say this then: 10 people for six million people? Whether it’s nurse-midwives, or Certified Professional Midwives, or even obstetricians. I think we have a problem.

NOBLE: I would not disagree with that.

WATSON: I think we agree with that. That’s part of the workgroup’s effort to look at that problem.

DEL. REZNICK: Okay, thank you.

CHAIRMAN: Any additional questions for this panel? Thank you very much.

NOBLE: Thank you.

CHAIRMAN: Okay, let’s bring up Pam Casemeyer, Dr. Virginia Keen, Dr. Melissa Yates, Dr. Mark Siegel. Ms. Casemeyer, would you like to begin please?

CASEMEYER: Yes I would please. I am Pam Casemeyer. I am here today on behalf of the Maryland Chapter of the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the Maryland State Medical Society, and we are here in opposition, although I will tell you that we had not appreciated that the Health Department was going to offer a suggestion that this be worked on over the interim. And I want to start out my testimony by saying that that qualifies much of what we are going to say today. Not what we are going to say about the bill as it was introduced, or the language of this bill, but of the subject matter. And I guess that’s where I’d like to start. Please differentiate between whether or not we need to figure out how to deal with the fact that there are not enough providers doing homebirths if you want to make that available. What their education and training is, what is the structure in which they operate, what is the mechanism in which we assure if you want to expand the number of options for women, that you do it in a way that they are informed of the decisions that they are making and the choices and the risks and the benefits as they go forward. It is not to say that we are here at the table saying, 'Oh it can only be an obstetrician or only be a Certified Nurse Midwife. If you look carefully at our testimony-- in fact the ACOG testimony attaches a recent planned homebirth document from ACOG recognizing that there is a reason for women to have an option to know where they are delivering, but with that comes a lot

of issues that are separate and distinct from whether or not--this isn’t about, 'Should we have homebirth?' This is about, if we have homebirth, do we have a structure for it in the state that ensures that when women are making that choice, they are getting all the information possible, they are able to select professionals, that they are able to be sure are adequately educated and trained, and that there are adequate provisions to know that if something goes bad, whether it’s a Certified Professional Midwife, a certified midwife, a Certified Nurse Midwife or an OB, that there is something there to deal with the circumstances that go bad. It happens very quickly.

A bill was introduced--and I am going to take a minute, and I have with me Dr. Mark Siegel and Dr. Melissa Gates, who are obstetricians, and Dr. Virginia Keen who is a pediatrician. Interestingly enough--and I'm going to take a few minutes to walk through some of the specific language, why we think the workgroup is necessary, not because we want to stack the work group to not have it happen, but you’ve got 26 states they said that have dealt with this. I can tell you there are a tremendous number of provisions in some of the other state laws that are not in this bill. There are all kinds of issues not addressed in this bill that are addressed in states that have professional midwives recognized as a profession. And that is the point. This bill's here for you the first year, do we want a gazillion-year battle? No, but because the bill comes in and there is a perceived shortage of access doesn’t mean you immediately say,' hold everybody harmless,' and we've got to do it immediately. It says we have an issue we have to deal with, but we want to make sure when we deal with it, it's dealt with in a way that the women who choose this option can choose it, that they know what they are choosing, and the state has some ability to be sure what they have to choose from is a safe structure. And we don’t think the bill as written provides that, and we think that there is a lot of opportunity, if you are going to create additional capability for the expansion of access to homebirth, then you better be really sure that you are doing it in a way that you aren't creating unnecessary people having to be rushed to the hospital at the last minute because there wasn’t any communication ahead of time. And I am not saying that there aren’t horror stories in hospitals and in other settings, but why would you rush to create the structure for the licensure or certification or regulation or recognition of a professional in an area which-- maybe it’s great most of the time, and there is no problems, but when the problems occur, they are not insignificant, and they are not easy to fix, and they are not necessarily reversible. So you better be careful, and that’s really why we were here.

I want to walk through the bill, but I have a pediatrician here because no one has even said this. This bill says that it would authorize them to be able to treat a newborn for six weeks of their life! You’ll hear from the pediatrician. Six weeks is a long period of time. That has nothing to do with homebirth, absolutely nothing to do with homebirth. Nobody today yet has talked about the actual

language of the legislation, and we are glad to hear what the Department of Health has said in terms of bringing everybody to the table. I can’t tell you that we are here to say we think homebirth is a great deal, or that there is not dangers involved, but if you’re going to want to be sure that there is this choice available, please be careful on how you do it and look to the those other 26 states. We would say, as we are sitting here in our organizations, some of the states we think have done a better job than others. But we don’t know of any states-- and I could be wrong, because I haven’t read all 26 statutes - that have this bill as introduced with these provisions as the regulatory structure. I just wanted to say that. I know it sounds strong, but I don’t want you to interpret us being here as we’re going to be the barriers to figuring out how to deal with the objectives that Secretary Phillips outlined when she talked about what she thought this workgroup should do. Because we know we have infant mortality issues, we know we have access issues, we know we have challenges. I mean, one of the questions nobody’s asked yet is that we have 211 certified nurse midwives. Only a small number of them have asked to do homebirths. Some of that maybe is a question that hasn’t even come up yet, but is worthy of discussion, because when you ask your malpractice carrier, 'I'm a Certified Nurse Midwife but I am now going to add homebirth delivery to what I do in my practice,' and your malpractice premium goes through the roof? I decide that as a Certified Nurse Midwife, maybe I am not doing homebirth. It’s not that I am against homebirths, it’s that I can’t afford to do them. So there are issues involved with this and the access to these services that are not as simple as saying, 'We just don’t like them because they are not nurses.' It is much more complicated than that.

And I’d like to just bring up a couple of points in the bill. There are three different types of nurse-midwives now recognized in various states. There are Certified Nurse Midwives; we have them here. There are Certified Midwives; they are not necessarily nurses. That’s not what’s here. There are Certified Professional Midwives. There are two different certifying organizations for midwifery in the country. One of them we register has much more rigorous standards for ensuring adequate education and adequate experience before licensure. They are not physician-dominated organizations; they are midwifery certifying organizations, and they certify those Certified Nurse Midwives and Certified Midwives, which is different than Certified Professional Midwives. So when you say the word 'midwifery,' it’s not necessarily the same thing to all people. That’s a discussion that the state should have. What are these different levels? What are their educational requirements? What is the difference between the two certifying organizations, and is there is a reason that one of them is preferred over the other and why? I don’t think anyone could answer that question based on what we have heard today, so there’s that issue.

This bill actually says that regulations have to be developed, but it prohibits them from requiring a midwife to be under the supervision or direction, to require the assessment of a mother seeking by any other licensed professional to limit the setting. There is no – it almost prohibits collaboration. You’ve heard today, even if they’re licensed and able to practice, you want to make sure that they have some communication channels with their local hospital, with somebody. Maybe not coming in and overseeing what they are doing every single day, but so that if something goes bad, everybody knows what’s going to happen. This bill as it’s written will prohibit the regulations from requiring that. I am not sure that’s a good thing for us to have just endorsed a right with no further discussion.

There was a question asked about medications. The medication list is not that specific. In many other states that have licensed professional midwives, there is a much more prescriptive list of their scope of what they can do and they can’t do. They are operating, they are doing homebirths, they can be there, the homebirth industry may even be vibrant. They are the states that they reference when they say '26 other states,' but there is a much more definitive discussion in the statute of what that includes and what that does not include. So I really want you to understand, we’re not sitting here saying we’re never going to work with this. I think the Department’s suggestion was a good one, if want to deal with those objectives, but there is a significant number of things in this bill that causes great – there is nothing in here that speaks about the requirement for informed consent. Informed consent has a legal meaning; it has a legal meaning that all other health professionals have to operate under. Informed consent is quite broad. You have to do a lot of things with informed consent. There is no requirement for informed consent. That’s a very specific provision that many states have included in their licensing structure, because they want to make sure that women who are making this choice have full information about what they are choosing. So we are here saying that this bill--and we would assert in some regards, we have issues with the specific certifying organization as opposed to the other one, but maybe that’s a subject for you all to investigate further--but we have concerns about the lack of information that’s contained in this bill. Before you create the mechanism for licensure that has the great potential to create great risk-- and with that I think, maybe, if you can hear a little bit about the issues that come to play both from Dr. Yates and Dr. Siegel, who are obstetricians, and from Dr. Keen, who is a pediatrician, because again no one has even talked about the pediatric side of this equation which is not insignificant Then maybe you'll understand...

CHAIRMAN: Ms. Casemeyer, Ms. Casemeyer, I am going to have to ask you to conclude please.

CASEMEYER: Oh yes; I'm done. Thank you.

CHAIRMAN: Let’s hear from Dr. Keen.DR. KEEN: Good afternoon. I am Virginia Keen. I am a general pediatrician and the

immediate past President of the Maryland Academy of Pediatrics. I am here in opposition of the bill as it was originally presented. I do think you need to know a little about me. I am a strong advocate for child health and for public health. I sit on the Maryland Medicaid Advisory Board. I also am on the Maryland Morbidity, Mortality and Quality Assurance Committee, which is working to decrease infant mortality, and my personal practice is primarily in the care of children with special health care needs. Some births are dangerous, but most are not; although, I don’t think it’s 98% are not. It’s more than that. Like the Morheims, I personally do not believe in the medicalization of normal healthy pregnancy. In fact, when I had my own children, who are now 22 and 25, I never saw a doctor, I never saw the inside of a hospital, and I never had an ultrasound. My kids were delivered by Certified Nurse Midwives and in a freestanding birthing center, and I was thrilled to be able to have access to that service. I am very sorry it’s not available now. That’s how much I believe in midwifery. I do believe that every woman deserves to be attended in pregnancy and childbirth by a trained, licensed provider; a proficient provider whose practice is regulated and monitored. I understand that the amendments that are entered will slow this process down and allow us to create a structure, so that lay midwives could demonstrate competence and get licensure, and we could create structure to regulate and monitor their practices, and I entirely support that. However, I have trouble supporting allowing a lay midwife to be the sole provider for an infant up till six weeks of age. Babies, I think, should be cared for by a medically- trained provider either a physician or a nurse-midwife. I went to four years of medical school, three years of pediatric residency, which included six months of neonatal training. I had to sit for a series of exams and go through Maryland’s rigorous licensing process. My practice is highly regulated and monitored; not so lay midwives. Maryland neonatal mortality rate is embarrassingly high despite the wonderful progress that we’ve made, and that’s because the neonatal period is dangerous. Babies have congenital abnormalities, they get infections. The signs and symptoms of these are extremely subtle, and they can advance very rapidly and result in significant morbidity and death, and it takes a skilled provider to detect and intervene appropriately to save babies’ lives. So why would we allow laypeople to take responsibility for this really vulnerable population?

I would like to tell you a story, and no, I am sorry, I don’t have it documented in the literature, this is a story at my own practice. I was just a couple of years out of residency, two o’clock in the morning, I get a phone call from a mom. Her breastfeeding infant, who had been completely healthy, did not take his 10 o’clock feeding well, and now at 2 o’clock she couldn’t get him to eat either and she was wondering what she should do. I told her to hang up, call 911 and go to the hospital right away, because I knew that this was a peak age for presentation

for general heart disease that could be fatal. I called the ER, I told them to have the medication ready; within five minutes of arriving to the ER, the baby had and IV and was getting the medication and echo did show that the baby had this critical coarctation of the heart, and the next day the baby was having lifesaving surgery. Would a lay midwife be able to make that call in the middle of the night? I don’t know, because I don’t know what kind of training they get in pediatrics. Do you?

CHAIRMAN: Dr. Keen, I’m going to have to ask you to conclude please.

DR. KEEN: Okay. So I agree that we need better access. I agree that women should have a choice of delivering at home. I think they should have a licensed provider whose practice is regulated and monitored, but I can’t agree to having laypeople take care of newborns, and I hope that you would take that position out of the bill.

CHAIRMAN: Very good. Dr. Yates.

DR. YATES: Thank you I’d like to thank the committee, I know that it’s late. I am a physician, an OB/GYN, I am an assistant professor at Johns Hopkins Hospital, and in order to get to this position, I actually did twelve years of schooling after high school, including a four year residency at Johns Hopkins in OB/GYN, took four written board exams and an oral board exam in order to be board-certified as an OB/GYN, and I am here supporting Maryland ACOG. Maryland ACOG supports informed decision-making by women about their health care options, and as physicians, we inform, educate and respect our patients’ choices. In the current medical climate, we believe that teamwork is paramount. We use teamwork on labor and delivery to achieve healthy deliveries every day. ACOG supports the collaborative process model: the maternity care team, an integrated system with care with established criteria and provision for emergency intrapartum transport. And this would be the sort of model that’s used in the Netherlands, where they do have very healthy home births and they do have excellent outcomes. In order for a patient, though, to be properly educated regarding her decision to undertake a homebirth, she needs to have an opportunity to go through written, informed consent with a certified midwife. This should include information regarding the midwife’s experience and credentials, and instances where physician consultation, and possibly transport, should be sought. And we believe that these instances need to be spelled out specifically in the bill, as they are in many other states. All patients should be offered an opportunity to have a consultation with a physician at least one time during the pregnancy.

Additionally, we believe that there should be strict criteria regarding instances prior to delivery where a midwife must refer a patient for care with a licensed physician. Some examples of this, in our belief, would be multiple gestation, pre-term labor or pre-term birth, a non-cephalic or a non-head-down presentation,

such as a breech presentation, history of a prior cesarean section, preeclampsia or hypertension that developed either before the pregnancy or during the pregnancy, a history of diabetes that either developed prior to or during the pregnancy, cardiac or pulmonary disease, a history of major cardiac pulmonary or abdominal surgery. Additionally, again utilizing the collaborative practice model, there must be instances where transfer of a laboring or postpartum patient is mandatory, and ideally these collaborations would be set up prior to the instance of the homebirth occurring. This way, the patient is already known to the accepting physician in the hospital instead of the situation that many of us have encountered, where a patient shows up in a very emergent situation and decisions have to be made in order to admit her, and you might be able to make a better decision if you had all the information ahead of you. Examples of reasons where someone should have the need for mandatory transfer would include: a prolapsed umbilical cord, which is an obstetrical emergency; maternal hemorrhage, signs of fetal distress, again fetal mouth presentation, evidence of infection, also known as chorioamnionitis; again preeclampsia, maternal seizures or eclampsia, a laceration which requires an advanced repair-- and I think that needs to be spelled out in the bill--a retained placenta, or, as Dr. Keen mentioned, an unstable newborn.

Having a collaborative practice is essential during an obstetrical emergency. Provisions should remain in advance, again, for an accepting physician in hospital, keeping in mind that if a patient lives within thirty minutes of the hospital and you are able to hit the door within thirty minutes, that doesn’t necessary mean that it would be fast enough to avoid maternal-fetal morbidity or mortality in some instances. Certainly this could also be unavoidable in hospital situations. Only by having a strict certification program in place for licensed midwives, and having an integrated practice model, can we improve the outcomes for women to elect, after proper counseling, to deliver out of a hospital or a birthing center, and that’s why we oppose this bill. Thank you very much.

CHAIRMAN: Dr. Siegel.

DR. SIEGEL: Hi there. Hi Delegate Kelly, it’s very nice to see you again. I am Mark Siegel. I am an obstetrician/gynecologist, and I am the current chair of the Maryland section of the American Congress of Obstetricians and Gynecologists. I have been an OB/GYN at Shady Grove Hospital for thirty years, and I am here today to speak in opposition to this bill. One of the things that I do is that I am on a committee for the State, the State Maternal Mortality Committee, and when I accepted that assignment, it just somehow seemed strange, but every single person who is presented to that committee has died in childbirth. Every single one, and there is about eight of them that are presented at each meeting. I mean, it happens a lot more often that you would think. And so in a situation

like that, you say to yourself, 'Why would the state want to make the practice of medicine and obstetrics and having a baby, why would they want to embrace risk and increase risk to people?' I have had personal experiences with this, and I think it is important that we are not talking against homebirth, we are talking against who should be allowed to do it. Who should have the training to be recognized in the state as being certified to be allowed to do it? To me, it’s not just someone who has just had a high school education. I mean, all of you have had a high school education, would you feel qualified to go to someone’s home, and not have any backup, and just be taking care of everything yourself, and be responsible for the mother and the baby? I would hope not. I think it’s a very risky situation for everybody. I have had personal experience. I’m also a certified mohel, and I go to people’s homes and I do circumcisions. It’s a religious ceremony, and so some of the patients I take care of are not my patients. I only go there for the circumcision, and I went to one woman in Takoma Park, and I was just making conversation, and she was telling me that everything went well until the baby was born, but then they couldn’t stop the bleeding. She is hemorrhaging, she lost all the blood in her body. She had to be transfused twenty units of blood and she showed me her scar, which went all the way up her abdomen, and they were even giving her last rites on her way to the hospital, all because they couldn’t stop the bleeding. I mean, postpartum hemorrhage is horrible. It’s very scary. Yyou need a team to help you, and I think what Dr. Yates said, the thing that most impressed me about what she said was the concept of teamwork. You really do need everyone working with you; it’s not something one person in isolation should be entrusted with that ability and responsibility. Just yesterday, I had a delivery, and this was supposed to be a low risk patient. She had a normal labor, and just when the baby was born, the head, instead of coming out, it went back in. We call that the turtle sign, and it’s known to be the sign of shoulder dystocia. That’s where the shoulders are too broad to fit through the mother’s pelvis, and a lot of bad things can happen when there is shoulder dystocia. I turned to the nurse, and I said that I may have a problem with shoulder dystocia. She jumped on the bed and she gave just exactly the right maneuver to free up the baby’s shoulders. It’s called suprapubic pressure. She freed up the baby’s shoulder, and the baby popped right out. This is something that it was because I was part of the team that I had the luxury of being able to call someone for help, and having them help me and help the mom. So, you know, I have seen bad things can happen. I think you know this type of experience because you are in isolation, you know if you’re far away from the hospital, you just have to call 911 and hope for the best. You know, once there is a lack of oxygen to the baby, there is ten minutes before you know, irreversible changes occur, and how can you even hope that the ambulance will get there in ten minutes? I just think that it’s too dangerous for untrained people to be doing it, and so, you know, that’s why I myself personally and the Maryland section of ACOG speak against it. Thank you.

CHAIRMAN: Questions for this panel? Thanks. Delegate Kelly.DEL. KELLY: Dr. Siegel, so nice to see you again.

DR. SIEGEL: Nice to see you.

DEL. KELLY: Thank you all for the work that you do. We really do appreciate the work you do, and you guys had so much wonderful and important things that I think do need to be considered as we move forward with figuring out how to do this and how to do this right. My question, I guess, is just to Ms. Casemeyer. So we want to do this right. I think that we need the midwives to be at the table for these discussions. So how do we get there? The same questions I had for DHMH. How do we get there with the current ban?

CASEMEYER: I don’t know that I can--I am not a regulatory person but when I--there is an awareness that this has been happening for a while. I mean they are here, they talk, they do their work, it happens. We have good things that happen, bad things that happen in all settings. I understand that they are not recognized at the moment. I am not sure that it’s that different than--I’ve been--I mean, I'm old, I've been here for 25 years and almost 30, and you know, we have created new disciplines and new professions, and some of them were doing what they did while before they were licensed or certified. That’s not an entirely new concept. Can I make any assurances? No, but I don’t know the answer. I do think it’s scary to say that everyone is held harmless, because if 99% of them do their work well, then you hold them harmless then the bad case is held harmless. I that’s a scary precedent too, so in some way there has got to be a bit of a good faith and it’s happened in all these other states. It’s been no different, and they have worked through it and they’ve gotten their licensure. They weren’t at one time, and they became at one time, and I don’t know. I’ll ask, but I don’t know of a single state that said, 'Okay, for one year we’re just not doing anything, it’s okay without regulation.' I don’t think that the case in anywhere where they’ve dealt with it.

DEL. KELLY: I think there is precedence for starting with the registry, so I can get you some information on that. I think we’re all in the same place to the extent that we know we need to address this, so I thank you for that.

CASEMEYER: Okay, thanks.

CHAIRMAN: Questions? Thank you very much I appreciate your testimony here today. Let’s bring up Lisa Walters, Erin Wright, Julia Pitcher. Ms. Pitcher, would you like to begin please?

PITCHER: Yes sir; thank you. Mr. Chairman and members of the committee. Julia Pitcher, on behalf of the Nurse Practitioner Association of Maryland, which is the

umbrella organization for nearly 3,500 advanced-practice nurses in the state and we actually had an evolution of our testimony. We were signed up as opposition to the bill as written, and I believe my colleague Ms. Casemeyer did a very good job in expressing the reasons for the opposition of the bill as written. Our opposition to the bill as written grants-- you have our letter actually as well so I will be brief-- grants the professional midwives more authority than all advanced practice nurses--whether they are midwives, primary care, acute care--more authority than they have now as college graduates, graduate degrees and doctorate degrees. So that is an issue for us, that the bill went beyond the scope and the authority that nurse practitioners already have currently. So we’d like to scale that back and look into that. So that’s why we feel that the workgroup is a good idea. Second, we working with the delegate and her office-- and I commend her aide, she has been incredible to work with--regarding the registry. We felt that we could live with the registry components; however, putting the registry out there, how do we guarantee that the legislature is going to come back and enforce more of that with the Board? There are no sanctioning guidelines; there is no titled protection; there isn’t anything that gives it any teeth for what if-- for right now, this is what advance practice nurses have to follow [shows book]--all of that, and if they get in trouble and go beyond their scope, the board can use this. So with the registry there isn’t that teeth to that point, so we’d like to work further on that.

Our testimony, has now gone to more of the support with amendments. We do love the idea of the workgroup and I don’t that will be killing any of the issue. I believe that it was Delegate Costa earlier who mentioned the task force on access to care and reimbursement. I too sat through two years of those meetings. At that time it was physician-centric. There is also the rule task force to improve physicians in Maryland. Let’s talk about nursing, let’s put it out there. The workgroup I believe that the DHMH has proposed talks about the access to care, talks about the issue for these professional midwives who are currently in this room, and the Certified Nurse Midwives that are currently able to practice under the Practice Act. Let’s talk about that, let’s get that out there. Maybe this is the time to make this a little bit bigger of a issue than such a narrow workgroup. So with that, I also want to give a quick apology, our current president of the Nurse Practitioners aAssociation is expecting a baby and is on bed rest-- irony of the day – and couldn’t be here. So with that, we are no longer in opposition of the different amendments that are going out there, but we would prefer to go forward with the DHMH amendments. Thank you.

CHAIRMAN: Ms. Wright?

ERIN WRIGHT: Good afternoon. I am here on behalf of the American College of Nurse Midwives- Maryland state affiliate chapter. Certified Nurse Midwives are supporters, providers and consumers of homebirth. We believe for women with

no special risk factors, homebirth is a safe and appropriate option when attended by a skilled provider with a clear plan for consultation and collaboration with other health care providers as indicated by the mother’s condition, and emergency transport when needed. We believe that the women of Maryland do not have the options for homebirth that they should be afforded. We are acutely aware of the barriers that exist for homebirth midwives, even those of us who are licensed CNMs. In light of this, we regret that we cannot support the legalization of Certified Professional Midwives in Maryland as it is currently proposed in House Bill 1056, while still remaining reflective of our national organization’s position statement regarding midwifery certification. In accordance with our national organization’s position, the Maryland affiliate of the American College of Nurse Midwives supports the licensures of CPMs who have completed a formal education program accredited through the US Department of Education. The International Confederation of Midwives, as well as the World Health Organization, also hold this position. Therefore, since this bill falls short of assuring a specific midwifery education requirement, we cannot support it in its current form. We would welcome the opportunity to meet with the bill’s authors in support to discuss strategies to ensure CPMs can be licensed in Maryland while meeting national and international midwifery education standards.

Our second concern is related to a lack of specific mechanism for collaboration and emergency transport. The ability to collaborate with other health professionals and effective, timely transfer up to a higher level of care, should it become necessary, are recognized globally as key proponents in reducing maternal and newborn morbidity and mortality. We understand that it is difficult to make such arrangements in Maryland, where the health care system has historically been hostile to homebirth families and to their providers, regardless of their certification or training. Significant legislative, regulatory and attitudinal barriers exist, making it difficult for even the most competent and educated Certified Nurse Midwives to transport patients who require care that falls beyond the midwife’s scope of practice without fear of litigation or retaliation. This occurs even when practicing in accordance with stipulated practice guidelines, and when the midwife is recognizing a variation from what is normal and transporting because it is the safest option for the mother and the baby. We would welcome the opportunity to join our hospital administrators, physicians, nurses, Certified Professional Midwife colleagues to find a way to provide the seamless continuity of care that make homebirth with a qualified attendant safe. We strongly believe that there is room for both Certified Nurse Midwives and Certified Professional Midwives to serve the women of Maryland, and we are painfully aware that the CNMs cannot meet the current consumer demand for skilled attendants at homebirth in our state. We seek a constructive, open dialogue with our professional colleagues that will help insure that every health care professional can practice to the full extent of his or her license. We

strongly invite all stakeholders, including consumers, to re-examine this bill in the coming months. Our goal is to find a language that will both meet Maryland’s families' right to birth with a provider of their choice, and ensure the highest level of safety for those child bearing families. The Maryland affiliate of ACNM strongly believes CPMs can demonstrate safe care in the home setting, and we look forward to working with them and the families here today to achieve that end. Recognizing that it’s every woman’s right to decide where her baby would be born and who would provide her care, and that it is incumbent upon the health care community to make all of those choices as safe as possible, we look forward to a day in the near future when all care providers can work together to provide the women of Maryland access to the full spectrum of birth options to which they are entitled. Thank you.

CHAIRMAN: Okay, Mrs. Walters.

LISA WALTERS: My name is Lisa Walters. I am a constituent of Delegate Ready. I am not

representing a professional organization. I am a wife and mother of six children; two of whom are hospital birth and four of whom were homebirth. My sixth child also died after home birth. I was attended by a CNM whom, because of the credential that she carried, I assumed was proficient. I did not receive full disclosure of things that were being held against her from previous investigations. My ability to make informed consent was severely compromised, and in the end my daughter paid for that. Is something in place that will allow for open disclosure of whomever you decide to license in this state? Birth in itself is not inherently safe; the chance of risk happens all the time. I would have been considered the ideal candidate for homebirth, having previous healthy children and no complications at all, and I still ended up with a death because things, once they go wrong, the amount of time you have for transport is not minutes. It’s not twenty minutes, it’s not thirty minutes, it’s seconds before brain injury happens and things are not recoverable. As it stands right now, it doesn’t seem like there are enough things in place to truly prevent that from happening just by widening the field of providers, instead of narrowing it down, and truly holding who we already do license truly accountable. Who is the accountability for CPMs?

CHAIRMAN: Okay, question. Delegate Reznick.

DEL. REZNICK: To the lady from the Certified Nurse Midwives. Sorry, I just got that all out. Quick question for you. You said that the organization is in full support of homebirths.

WRIGHT: Yes.

DEL. REZNICK: Why is it that only ten out of 211 of you, then, are certified to do it? WRIGHT: I am delighted you asked that question. One of the reasons is because of the

barriers that exist legislatively and regulatorially. While some of those barriers--the written practice agreement, which was replaced by a new collaborative plan--that were supposed to ease some of those barriers, unfortunately they haven’t really. Unfortunately you still have to be able to identify, publicly, a physician who is willing to back you up, and while there are many physicians who would be more than happy and will express to you privately that they are very willing to back you up, and they are very willing to help provide emergency care or referrals, and collaborate with you, they are afraid to do so publicly, because of the stance that their hospital may have on homebirth, that their professional organizations may have as an opinion on homebirth, and so because of that, it’s very, very difficult to find someone who would publicly admit that they are very willing to do this for you.

DEL. REZNICK: There was a point made earlier about malpractice premiums. Is there a particular difference between Certified Nurse Midwives who do homebirths and who don’t do homebirths with regard to malpractice premiums?

WRIGHT: You know, I actually work in the hospital birth setting; however, there are no health professionals in the state of Maryland right now that are required by the state to have malpractice insurance. They are required by sometimes their hospital or their employer, or they mainly will choose to. Many CNMs who are not, say, working for an institution that requires it, choose to have the malpractice insurance. Whether or not that has increased or decreased...

DEL. REZNICK: It’s always a good idea to have the malpractice insurance for any professional - what they be – doctor or lawyer or anybody. The question though is, would you know--and if you don’t, if you could find out for us, I would really like to know.

WRIGHT: I can absolutely find out that information.

DEL. REZNICK: If there is a difference, and what that difference is, between nurse-midwives who do homebirths and don’t do homebirths.

WRIGHT: We’d be happy to do that for you.

DEL. REZNICK: Thank you.

CHAIRMAN: Any additional questions? Thank you very much.

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