Public Health Law Map - Beta 5 - Medical and Public Health Law Site

profound differences in the underlying medical care systems.
Except for women having contractions, there is no guaranteed access to medical care
for pregnant women in the United States. In many states, there is little regulation of the
training and competence of lay midwives. The underlying morbidity and mortality of
the population generally, and pregnant women in specific, is higher than in Europe,
and it is dramatically higher in many low- income areas. These factors increase the
percentage of women who will need physician-directed care during pregnancy or
delivery. Most problematically, women who choose midwives because they believe
that the perfect baby results from a natural pregnancy will be especially intolerant of
pregnancy- related morbidity or neonatal mortality. The anger, and litigation, will be
directed at the obstetrician because the midwife will usually transfer the patient before
the disaster.
These factors contribute to, and reflect, the lack of a rational system for midwifery
practice in the United States. This makes it legally risky for obstetricians to work with
independently practicing midwives. Midwives also pose ethical problems for the
physicians who are called on to treat their patients. It is not unusual for lay midwives
in states with weak regulations to avoid physician referrals until there is a crisis, and
then to refer the patient to the emergency room. Many obstetricians want to help the
patients of such midwives but do not want to be seen as endorsing their practices.
Financial issues complicate the relationship between obstetricians and midwives. Some
obstetricians oppose midwife practice as unwanted competition, whereas others
employ midwives to increase their patient base. In smaller communities that can
support only one or two obstetricians, extensive midwifery practice drains off the
routine deliveries that are the financial base for obstetric practice. This increases the
pressure on the obstetricians to shift to gynecology-only practices or to leave the
community, compromising the availability of surgical deliveries and other medical
interventions for all pregnant women in the community.
1. Classes of Midwives
Referral and consultation practices vary with the class of midwife. Nurse- midwives
are registered nurses with specialty training in midwifery. All laws governing
nursing licensure and practice apply to nurse-midwives. As a consequence, nurse-
midwife practice is usually well regulated and reliable even in states that do not
otherwise regulate midwives. Although there are special considerations in working
with independently practicing nurses, referral and consultation with nurse- midwives
does not pose the ethical and legal problems of working with lay midwives.
The training of lay midwives varies enormously. Some have been through extensive
training and apprenticeship programs; some may be physicians or nurses who are not
licensed in the United States; others are self-taught from books or experience; and
some have virtually no training or skills. A state may license and regulate lay
midwives as extensively as nurses or physicians, but few do. There are contradictory
reasons for allowing lay midwifery. Some groups argue for lay midwives because of
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