"Thanks very much for sharing your concerns. As a candidate I do support choices in healthcare, but as for the issue of midwifery I do believe this was addressed during last year's legislature and that midwifery is now legal in South Dakota. You may wish to review the law passed during last session to see if additional legislation is still actually needed..."
[A reply from a legislative candidate regarding willingness to support CPM legislation.]

"We took care of the midwife problem." "We gave the home birth families CNMs, which is a better kind of midwife..."

Last year the Department of Health, Boards of Nursing and Medicine came forward with a bill regarding home birth and midwifery. They offered the bill "in response to the needs" of the home birth families. So why are we still complaining?

The CNM-home birth law in South Dakota:

36-9A-17.3. Waiver of collaborative agreement requirement. The boards may waive the collaborative agreement requirement for a certified nurse midwife, licensed under this chapter, who provides out-of-hospital birth services in accordance with practice guidelines established by the boards. (This section is repealed effective June 30, 2013 pursuant to SL 2008, ch 193, § 2.)
Source: SL 2008, ch 193, § 1.

The law fails CNMs:
This law does not provide for true autonomy of practice for CNMs. While an out-of-hospital birth practice does not require a signed collaborative agreement, the rest of CNM practice still does require the permission of a physician. A CNM must be willing and ready to do a home birth-only practice because taking the waiver will put the collaborative agreement covering the rest of her practice in jeopardy.

The use of a signed collaborative agreement for CNM practice is a model practiced in only a handful of states. The majority of states perceive this model as restraint of commerce with a high potential for misuse to limit "competition" in women's healthcare services. Ending the signed collaborative would have provided CNMs the protection and autonomy to maintain a traditional office practice and to develop a portion of it to include home births. However, proposals to eliminate the agreement and have CNM practice regulated solely under the Board of Nursing have failed in South Dakota.

The law does not protect a CNM from discrimination or harassment from hospitals. It has happened in
the past that providers and even consultants of home births have found their hospital practice privileges threatened because of their support of out-of-hospital births. The law does not protect a CNM from discrimination by her malpractice insurance carrier. In recent years insurance companies have increased rates for CNMs (and family physicians and OB/Gyns) such that they can no longer afford to provide birth services. Numbers of birth service providers continue to decline under this pressure. Malpractice insurance coverage has also been denied birth service providers who serve clients in a home setting.

The law is misleading to the citizen legislature of South Dakota:
Many of those who voted to support the CNM law did so believing they were finally able to meet the needs of home birth families. The sponsors of the bill that became law did not make it clear that CNMs as a profession seldom attend home births*; that the structure of the waiver would make it nearly impossible for CNMs to attend home births and still have a connection to their usual means of conducting their profession and earning a living; and that the families seeking home birth services were requesting the services of midwives specifically trained in home birth (CPMs), rather than professionals who might occasionally step outside their box and endeavor to develop these specialized type of birth service skills and philosophy.

The law fails home birth families:
Physicians are "permitted" to attend homebirths under current South Dakota law. But with fewer than one in 10,000 physicians practicing home birth today, the legality of physicians in the home birth setting is nearly irrelevant for South Dakota families.

This new law also "gives the option" of a Certified Nurse Midwife to provide home birth services. However this "gift" did not really make much of an impact because fewer than one in 1,000 CNMs choose to provide home birth services. Home birth is not much more of an interest for CNMs than it is for family physicians. While both professions are well trained in birth services, none of their required training is done in the home setting and working out-of-hospital appeals to very few of either profession.

The families who choose home birth and want this option available for themselves and for their children who will one day be mothers and fathers themselves have been quite clear about the kind of midwifery care they are seeking. While the CNM waiver law was developed by the Department of Health, the Board of Nursing and the Board of Medicine and their support of it focused on "highly educated" midwives, the families seeking midwifery care are instead seeking midwives specifically trained in home birth. The CPM is the only nationally accredited credential specific to home birth, and the most reliable assurance to home birth families that the provider they are engaging is experienced in home birth and practicing without the invisible external pressure of physicians, hospitals, and insurance companies who are ultimately having a hand in how a CNM practices.

*According to the National Vital Statistics Report for 2005, only 1.3% of the births attended by CNMs were in homes.

Quick Summary:

* Families and legislators must be made aware that the CNM waiver for home birth does not meet the needs of South Dakota home birth families.
* Supporters of autonomy and choices in healthcare must be prepared to provide strong support for the time which will come when CNMs do seek their independence from dual board licensing and the signed collaborative agreement. When CNMs have true autonomy they will be better able to serve the needs of women in the clinic, hospital and, for the few that choose it,
the home.
* The CPM is the only nationally accredited credential specific to home birth.
* Access to CPM care is what the families concerned with home birth have been seeking through their years of community activism.