Missouri court says midwives can continue to practice

A recent Missouri Supreme Court decision left intact a law allowing certified professional midwives to practice independently. Physicians fear the ruling leaves patient care in jeopardy.

The midwifery provision was tucked last minute into a bill designed to make health insurance more accessible and portable, and Gov. Matt Blunt approved the measure in June 2007. Previously, the practice of midwifery was outlawed in the state. At least 24 other states have legalized the practice, according to the Missouri Midwives Assn.

As the ink dried on the newly signed law, four physician organizations -- the Missouri State Medical Assn., Missouri Assn. of Osteopathic Physicians and Surgeons, Missouri Academy of Family Physicians and St. Louis Metropolitan Medical Society -- sued the state. They challenged the constitutionality of the provision giving certified professional midwives the right to deliver babies without physician or state oversight.

Doctors argued that since the provision had nothing to do with health insurance, it violated constitutional requirements that all bills have a single subject, expressed clearly in the title, and remain true to that purpose. They also contended that when complications arise during home births, doctors would be the ones called to handle the high-risk emergency care.

In a 5-2 opinion, the high court in June rejected the physicians' lawsuit, saying the groups did not have standing to sue. As a result, the court did not address the constitutional questions raised. Instead, judges tossed out a trial court ruling that invalidated the statute and blocked it from taking effect. The law is now in force.

Doctors decried the ruling, citing a host of patient safety concerns.

"What the Supreme Court said was physicians are effectively not allowed to advocate for their patients," said Jeff Howell, general counsel to the Missouri State Medical Assn.

The organization said it is exploring other legal and legislative options to overturn the midwifery law.

Doctors question qualifications

Certified professional midwives do not share the same level of knowledge and training as licensed physicians and are not qualified to handle a wide range of unexpected complications without physician supervision, doctors said in a friend-of-the-court brief filed by the Litigation Center of the American Medical Association and State Medical Societies.

David L. Redfern, MD, a Springfield, Mo., ob-gyn, said 10% to 15% of home births require an emergency hospital transfer. Without state regulation, however, midwives are not required to spell out a backup plan. Nor are they subject to discipline if anything goes wrong, he added.

"When midwives' mishaps end up in the hospital, physicians are ultimately charged with that responsibility," Dr. Redfern said.

Two dissenting judges agreed and said they would have ruled the midwifery provision unconstitutional.

"Physicians are in the best position to effectively advocate for their patients' rights because of their expertise in this area and familiarity with the risks of the procedures, and because they will ultimately be called upon to actually participate in the care of mothers and infants in instances of error or unforeseen complications," Judge William R. Price Jr. wrote.

Delegates at the AMA's Annual Meeting in June echoed similar concerns. They adopted policy in support of state legislation calling for physician and regulatory oversight of midwifery practice.

Delegates also voted to have the AMA advocate for state legislation recognizing that the safest settings for deliveries are accredited, freestanding birthing centers or hospital-based birthing units that meet American Academy of Pediatrics and American College of Obstetricians and Gynecologists standards.

Mary Ueland, legislative chair for the Missouri Midwives Assn., said the state's midwifery law was intended to encourage collaboration in patient care.

Ueland said certified professional midwives in Missouri are trained under national standards established by the North American Registry of Midwives.

Midwives also are credentialed by the National Organization for Competency Assurance, which certifies other nonphysician health care professionals, such as nurses.