Women in rural parts of South Dakota might have to travel 100 miles or more to give birth in a hospital. For this and other reasons, some choose to give birth at home, but obtaining qualified healthcare providers to attend to them at home is presently almost impossible.
Of the 21 certified nurse midwives (CNMs) in the state, those who practice do so in hospitals and clinics under a required formal collaborative agreement with physicians. Many states have no such requirement.
Physicians in South Dakota do not attend home births and are largely unwilling to enter into a collaborative agreement for home births because of the liability they could have if something goes wrong.
Another group of providers, professional nurse midwives known as direct entry midwives, are not certified by the state's nursing board and are unable to provide these services lawfully. This group, whose training differs from that of CNMs, has attempted without success to persuade the South Dakota legislature to legalize its practice. They are represented by the National Association of Certified Professional Midwives (NACPM).
Not all CNMs in South Dakota practice under the collaborative agreement requirement. Several midwives work at the Pine Ridge Indian reservation for the Indian Health Service. They are licensed in other states that don't have the requirement and practice as federal government employees.
CNMs in the state are jointly regulated by the South Dakota Board of Nursing and the South Dakota Board of Medical and Osteopathic Examiners in Sioux Falls.
"We have been proposing a compromise on this problem that would allow some flexibility and a waiver by the two boards of the collaborative agreement requirement in certain home birth situations," said Gloria Damgaard, RN, executive director of the nursing board. "But the medical community has not agreed to that." Calls to the medical board were not returned.
Part of the collaborative agreement requirement is that all advanced practice nurses, with the exception of nurse anesthetists, must spend four hours or 10% of their time a week in the same facility with their collaborative agreement physicians, and in South Dakota that can mean driving 60 or more miles for that purpose. With a population of about 800,000 people, South Dakota ranks 46th in population, but its area of about 75,000 square miles makes it 16th in size nationally.
CNMs can practice in hospital or clinic settings, and doctors are willing to enter collaborative agreements for this kind of practice. Lisa Van Gerpen, RN, CNM, is a hospital-based CNM in Sioux Falls with a collaborative agreement with the obstetricians with whom she works. They do not attend home births.
"The collaborative agreement has not caused any difficulty for me because I work in a big enough city that we have options for physicians to work with and have an easier time obtaining a collaborative agreement," she said. "But it can be a problem for people who work in small towns."
Jeanne Prentice, RN, is one South Dakota CNM who would like to attend home births in small towns. Her practice includes home births in Wyoming, where she also is licensed and where CNMs are permitted to attend home births. She has a dual residency in both states. Prentice is seeking approval from the legislature to waive the collaborative agreement requirement and grant sole jurisdiction to the nursing board. Her 2006 request to the legislature was not approved.
Prentice said liability insurance for midwives could run $25,000 a year and if the CNM were to do one or two deliveries a month, he or she wouldn't earn enough to cover that. She said other avenues, such as arbitration, exist for handling disputes that could arise.
She believes the collaborative agreement requirement creates an access to care issue, particularly for those who choose to give birth outside of the hospital.
"This is a conservative, rural state, and many people choose home birth and are delivering unattended or with lay midwives," Prentice said. "Some of us are more than willing to step into that role but aren't able to. This is about money. Obstetrics is a very lucrative business. It is simply a way to control the midwifery practice and force patients to use certain providers and hospitals."
Anthony Diehl, MD, who practices in Rapid City, has worked with midwives and respects their abilities. However, he believes there should be backup by a physician available. He has seen patients who appeared to be low-risk candidates and would seem well-suited to home birth, wind up with serious, unexpected problems. He agrees access is a huge problem that will worsen as family practitioners in rural areas close up shop because of the expenses of practicing.
"It's an issue of choice for home birth moms," said Susan Rooks, RN, South Dakota chapter chairman of the American College of Nurse Midwives. "To tie the hands of the very people who can help moms in home birth situations is a health safety issue."
If the collaborative agreement requirement were removed, it is unclear whether CNMs would be able or required to obtain liability insurance for their practices. Prentice doesn't think it would be necessary because home birth mothers, in her opinion, are not particularly litigious and are grateful for the help they would be able to receive from the CNMs.
But Mark Ballard, MD, who practices out of the Rapid City Regional Hospital, believes any practitioner practicing without medical malpractice insurance is taking a huge risk of losing everything.
Ballard said, "The doctor would be practicing medicine without malpractice coverage. My medical malpractice company is clear about exactly where I can practice and won't cover me at any other location."
He works with a midwife in his practice who takes care of patients during pregnancy and attends deliveries, with an obstetrician on call to back her up. He understands the frustration of midwives who are unable to provide home birth care and the access issue for rural patients, but he also understands why doctors don't want to participate.
For now, the controversy continues and both Prentice and NACPM are likely to continue their efforts with the South Dakota legislature.
Barbara Kois is a freelance writer. To comment, e-mail editorHTL@nurseweek.com.