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Legal Aspects of Midwifery

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A Holiday Treat from gentlebirth.org
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See also:

Subsections on this page:



General Information



From Calling to Courtroom, Inc. - A Survival Guide for Midwives - An online booklet with a great state-by-state resources section in the sidebar.


How to Ace Your Deposition to Help Win Your Malpractice Trial - The way you act at your deposition, the way you prepare, and how you behave can play a major role in whether you win or lose your malpractice case.



Legal Advocates for Birth Options and Rights (LABOR) - A gathering place for lawyers, law students, and others interested in legal issues surrounding childbirth.

Always speak about your professional midwifery work as legal - Whether or not you are a licensed midwife, please, please, please do not EVER say that what you/we are doing is illegal. Not any of it, not anytime, if it can be read or overheard, i.e. in public.


Senate Approves Patients' Bill of Rights by Wide Margin - July, 2001 [Medscape registration is free]


FindLaw has an interesting article on Horizontal Restraints Among Competitors, also called price fixing.


Online lawyer - law office


The Trials of the Midwife
by Katie Granju - From Minnesota Parent, October 1997
A must-read article for anyone trying to understand why the healthcare system in the U.S. continues to snub the midwifery model, despite reduced Cesareans, proven safety, and lower costs.


The California Health Freedom Coalition (CHFC) sponsored a law that recognizes the professional legitimacy of alternative and complementary health care practitioners and healers allowing them, for the first time, to be able to legally provide and advertise their services in California.


The Intersection of Mommyhood and The Law - Blawg Review #158 - Monday, May 05, 2008 on the occasion of International Midwifery Day.



HIPAA - Health Insurance Portability and Accountability Act / Privacy



See also: Money and Paperwork / HIPAA Protections


I was attending a seminar on "Midwifery on the Web 2.0", and we discussed client privacy.  She said that her own personal litmus test is, "Would she be able to identify herself".  She also said that some blogging midwives ask their clients if they can share anonymous stories on blogs or facebook.  Good idea!


HIPAA Compliance Resource Center [Medscape registration is free]


HIPAA Administrative Simplification


Don Self's web pages have some good sample forms for HIPAA compliance.


Internet Use in the Laboratory:   The webcast is approximately 60 minutes long consisting of the audio presentation and accompanying slides.- a CME course with info about HIPAA


HIPAA Privacy Rule and Public Health - Guidance from CDC and the U.S. Department of Health and Human Services


Final HIPAA Privacy Rules - February 20, 2001 - from the Dept. of Health and Human Services
Their SAMPLE BUSINESS ASSOCIATE CONTRACT PROVISIONS
Their FAQ - Frequently Asked Questions and Answers, including "Generally, what does the HIPAA Privacy Rule require the average provider or health plan to do?"


State & Territory Governments HIPAAlinks


State of California's in-depth Office of HIPAA Implementation (CalOHI) web site. Find out about California and federal legislation and regulations, preemption of California State laws by HIPAA and timelines that apply to HIPAA and related subjects, such as privacy. Contains a report to the California Legislature on the impact of HIPAA on California State departments, as well as FAQs, samples of templates, contracts, forms, sample implementation plans and training plans.
Of particular value:
HIPAA 101 - Basic information


Road Map to HIPAA Compliance for the Provider - from the Medicaid site


CAL HIPAA - A fee basied site about HIPAA, the Health Insurance Portability and Accountability Act, includes strict, far-reaching requirements in 2002/2003 for  an estimated 23 Million  American health care  providers to insure the  confidentiality and privacy  of patient information.


The Midwife's Billing Service is offering a booklet (18 pages), which distills the information that is most helpful to midwife practices.  (You can order it at 978-544-3551)



EMTALA / Anti-Dumping Laws



The Emergency Medical Treatment and Active Labor Act (EMTALA) has specific regulations for hospitals relative to women in active labor.  The purpose of these federal regulations is to ensure that patients with medical emergencies, including women in labor, are not denied treatment based on any reason other than those that reflect the hospital's capacity to examine, conduct tests, and treat the emergency condition.

All women in true labor are considered to have an emergency medical condition, and are therefore unstable. "Labor" is defined under EMTALA as the process of "childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta."[1,5] The presence of an emergency medical condition triggers all of the obligations of EMTALA. 


This is taken from the Winter 2006 - Number 76 issue of Midwifery Today:

"The federal Emergency Treatment and Advanced Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment wishes until the baby and placenta are delivered. The act was originally passed to prevent hospitals from "dumping" patients who can't pay, but its since been applied in all sorts of other ways and includes specific provisions that apply to laboring women.

The attorneys we've consulted on the VBAC ban issue have told us that hospitals are much more afraid of being found in violation of EMTALA than they are of malpractice suits because the act is routinely enforced and each violation subjects them to fines between $50,000 and $100,000.

I can't emphasize enough the importance to individuals who may find themselves in this situation of memorizing phrases such as "It's a violation of my rights under EMTALA to force me to undergo a cesarean," or "I'm invoking my right under EMTALA to refuse a, b, c." Whether the hospital in question says it bans VBACs is unimportant; according to EMTALA, you have the right to be admitted to a hospital once you're in active labor and, once admitted, you have the right to refuse any recommended treatment. You can also remind them that VBAC isn't a treatment, it's the natural culmination of a normal physiological process. Cesareans are the treatment.

Also, it's helpful to know that EMTALA begins to apply once you are anywhere within 250 feet of a hospital; you don't have to be in the emergency room. You can be standing in the hospital parking lot, and if they so much as touch you against your express consent, they are in violation of EMTALA. For anyone interested in reading more, we've compiled a legal primer on the rights of pregnant women at http:

Editor's Note: To learn more about this important subject, go to http: . There you will find frequently asked questions (FAQ), as well as links to the statue and case law." 



Religious Practitioners



Faith Gibson's Wealth of Information, especially regarding Religious Practitioners. Exemption for Religious Practitioner - California Article 24, 1917 Exempt section 2063.


Doctrine of Self-Care

As explained to me once by a lawyer -- We have a legal term called the "doctrine of self care" which means any competent adult can ask any other adult to do a "medical procedure" on the requesting adult. It would not be legal for a person to suture or inject meds or to advertise this or "prescribe" or even to "suggest" .. but he/she is allowed to honor another adults request. In other states, it might be different. 

Informed Consent



Informed Decision Making, Informed Consent or Refusal from childbirthconnection.org


Leaving against medical advice: Should you take no for an answer? - Free CMEs - This course will discuss the medicolegal risks to the physician, nurse, and hospitals associated with a patient leaving against medical advice (AMA) and provide strategies to prevent patients from leaving.


Informed Consent: Practices and Views of Investigators in a Multinational Clinical Trial [9/27/05 - Medscape registration is free]


MIDIRS offers Informed Choice leaflets


ACOG can be a good source for patient education pamphlets aimed at good liability defense.


Doctors spell out risks of childbirth on consent forms [August 09, 2004] - Seven Seattle obstetricians are drafting a consent form for pregnant patients, spelling out in graphic terms the dangers their babies face coming into the world, including death, "permanent severe brain damage" and other lifelong disabilities.


I wasn't sure whether to include this in the subsection on "Informed Consent" or "Lack of Informed Consent".

Getting a stubborn patient to say Yes - an article written by and for OBs about how to coerce laboring women to agree to routine treatment.

This is the actual practice of the theory expounded in Patient Choice and the Maternal-Fetal Relationship.


Court Ordered Medical Treatments And Legal Penalties For Potentially Harmful Behavior By Pregnant Women:

(1) Judicial intervention is inappropriate when a woman has made an informed refusal of a medical treatment designed to benefit her fetus. If an exceptional circumstance could be found in which a medical treatment poses an insignificant or no health risk to the woman, entails a minimal invasion of her bodily integrity, and would clearly prevent substantial and irreversible harm to her fetus, it might be appropriate for a physician to seek judicial intervention. However, the fundamental principle against compelled medical procedures should control in all cases which do not present such exceptional circumstances.

(2) The physician's duty is to provide appropriate information, such that the pregnant woman may make an informed and thoughtful decision, not to dictate the woman's decision.

(3) A physician should not be liable for honoring a pregnant woman's informed refusal of medical treatment designed to benefit the fetus.

(4) Criminal sanctions or civil liability for harmful behavior by the pregnant woman toward her fetus are inappropriate.

(5) Pregnant substance abusers should be provided with rehabilitative treatment appropriate to their specific physiological and psychological needs.

(6) To minimize the risk of legal action by a pregnant patient or an injured fetus, the physician should document medical recommendations made including the consequences of failure to comply with the physician's recommendation. (BOT Rep. OO, A-90; Reaffirmed: Sunset Report, I-00)

[From the AMA Guidelines.]


Words: Stark Foundations of the Euphemisms that Bind our Times - Words are used to control pregnant women: "evidence based practice", "woman centered", "choices in childbirth", "informed consent"- these terms mean little when medical application can be so ruthless.  [As of spring, 2002, the BirthLove site is by subscription only - it's well worth the $10 membership fee; you can get a "sampler" by reading BirthLove's Top Twenty- For Free!.]  [Ed: birthlove.com is not available at this time.]


Informed Consent Clouded by Technology, Marketing Pressures [Medscape registration is free]


Federal Legislative Draft Mandating Patient Empowerment and Medical Accountability - this is well worth reading for anyone who values the concept of true informed consent or informed choice.


I don't know about c/s situations, but I do know that any medical procedure that a person says "I do not consent to _______." in Texas is considered assault if the provider does the procedure in spite of the patient.  It's a great sentence to teach moms about episiotomies.


ICEA Statement on Informed Consent


VBAC Consents


Jude Stensland's collection of Consent Forms and other information sheets


Faith Gibson's pages on Informed Consent for Special Circumstances
Here are 3 "Special Circumstances" informed consent documents for home-based care and/or refusal of customary obstetrical protocols for VBAC, Twins, Macrosomia and her general page on Informed Consent


A comprehensive set of Informed Choice leaflets from the folks at MIDIRS (Midwives Information and Resource Service)----   each examines key decisions facing expectant mothers during pregnancy and is designed to assist them in making informed choices.   Vitamin K, Rho-gam, Ultrasound, Home, Hospital or Birth Center, VBAC, Breech.


Regarding those universal consent forms hospitals typically use,

Blanket consents (I consent to everything) and blanket releases (I release everyone from liability) are traditionally disregarded by the courts. They may be seen as an effort to misinform or deceive the client.
Jensen & Bobak, Maternity & Gynecologic Care, 5th Ed, page 77.

Consent may be given or withdrawn at any time, either verbally or orally. You can sign a consent for episiotomy on admittance but when the time comes if you say no don't cut me and the doctor still does, that is tort battery. MGC continues on the same page:

Client's refusal should be carefully documented and thereafter respected.
This is one of my favorite topics, it always generates excitement when couples learn that they can refuse a treatment. I do, however, tell them that flat out refusal and invocation of these legal rights by threat to the medical staff is a powerful weapon best used only in extreme cases. You catch more bees with honey than vinegar!

My psychiatrist husband (director of a state psychiatric hospital) reminds me that only the court can determine competency in the U.S. Physicians have no legal right to do so. Patients are presumed competent unless an interested party (usually the family, sometimes law enforcement, less often the hospital or physician) petitions the court and a judge rules the patient is not competent.

Any time a physician or hospital staff performs any procedure on any patient without the patient's consent (or the parent or guardian's consent in the case of a minor or incompetent adult), battery has been committed. Battery is a tort, but is an intentional tort not covered by most malpractice policies. It does not require financial damages as a medical malpractice (negligence) tort does.

So, I'd be careful about doing anything without consent, even if you think the patient needs it, and I don't use blanket consents to treatment. There's not a lot of money in battery lawsuits for attorneys, but some are noticing that since the malpractice policy doesn't cover it, physicians are more likely to settle quickly, so there's potentially less work for the attorney.

I guess my health law and patient's rights classes at the school of public health impressed me.


Hospitals Ignore Informed Consent, Override Parents' Choices or Report Parents

You have the  right to go to the nursery and pick up your baby and walk out of  the hospital.

But, just so everyone knows, if you do this, the nurses are required by law in some states to inform Childrens' Services.  And, if you get out of the hospital before they arrive, they will call or show up at your home and put you through a thorough investigation.  This happened to my mother with her 3rd child (taken to hospital for jaundice after a homebirth) and it was a threat made to me when I said I would check my 2nd son out AMA if they didn't stop trying to replace his IV.  It's not something to be afraid of, per se, just be aware that it could very well happen.


i would like to relate an incident that happened in a hospital that was not related to birthing. my son when he was little had moderately severe asthma.  he was admitted to the hospital on one occasion for treatment.  they had to monitor the levels of the medication in his system, which required drawing blood.  he was only 6. one lab tech decided she was going to take the blood while he was asleep.  i told her to wait until he woke up. she said no.  i said you WILL wait.  she started to do it anyway- i called the nurse.  before the nurse got there,  my son was screaming at the top of his lungs and so was i (how would you like to wake up that way!!!).  the only way i could have stopped her was by physical force. and i guess i could not believe she was really doing it when i had explicitly told her NO!!  this officious little snot of a lab tech defended herself by claiming she had a schedule to follow.  the nurse was appalled. we did not see that little snot for the rest of his stay.  one of the peds nurses did the rest of his blood draws-WHEN HE WAS AWAKE!!! grrrr.....

i guess my point is, some hospital personnel will have a difficult time taking NO for an answer, so we need to be prepared to fight if we have to!


Do we have a right to get up and walk out of the hospital during labor after we admitted to the L & D? Is it legal to do that? Will the guard arrest us if we do that? Do we have a right to go to the nursery and pick up our baby and walk out of the hospital without signing the discharge paper? Is it legal to do that? Will the guard arrest us if we do that?


I find it disturbing that culturally we give so much power to the medical system.

Why would it ever be illegal to leave the hospital?  You're not supposed to be under house arrest.  You're not supposed to be a prisoner of the state.

In theory, doing something to your body against your will is battery, and trying to hold you against your will is kidnapping.

You can even decline any and all procedures offered, even a cesarean.  If they do a cesarean against your will, you have a whopping big lawsuit on your hands.  Why do you think they're always shoving consent forms into your face?  I know it seems like a formality, as if they would do whatever they wanted anyway, and it's just a nicety for them to pretend that they're carrying out your wishes, but that's how it's supposed to be.

It bothers me when hospitals rob patients of their individual freedoms.  First, they're getting court orders to perform cesareans, then they're putting pregnant women in jail because their behavior might affect the baby.  How long will it be before they seek court orders against women who don't eat their vegetables?  The only thing holding them back is the numbers of such women, not the principles involved.


One thing I learned when my instructions concerning the baby were not followed despite having watched the document being stapled to my file is that the baby gets a file of his own and your instructions will not necessarily be transferred to his file.  So, if you have birth instructions and post-birth/baby instructions, make sure to have two separate documents and be sure your support person gets the baby's document into the baby's file and still monitors staff to make sure your instructions are followed.

After baby #1, my husband and I have an understanding that no matter what is happening with me, he is to stay with the baby.  Despite my express written instructions (for the child of two lawyers no less!), the nurse never looked at the document and my husband had to stop her from putting antibiotic cream in his eyes.  I feel sure he will have to do it this time as well.  The hospital registration documents included a hep b consent form.  I didn't just check "No" and sign - I added an addendum that any injection given to the child without the informed consent of the parents would be deemed a battery and would be the subject of legal action.

You can just never be too loud that you don't want your birth and/or your baby's treatment to be done with everyone on auto pilot.




Lack of Informed Consent



Preganant woman's rights get short shrift - OB and lawyer get court order to force a woman to submit to a cesarean against her will.
[July 20, 2001 at Memorial Hospital in Jacksonville, FL.  OB: Neil Sager; Lawyer: Harry Shorstein, state attorney for Duval County.]


Case on Court-Ordered Bed Rest Highlights Reproductive Rights Concerns for Pregnant Women (1/13/10 about Florida, March, 2009)

Is Refusing Bed Rest a Crime? By LISA BELKIN(1/12/10 about Florida, March, 2009)




Midwifery Scope of Practice



Midwives can't use forceps or vacuums, or perform intubations because it's not in their scopes of practice. Heaven help any licensed or unlicensed midwife who attempts these procedures and causes an injury. Taking an IV skills class can get you a certificate at least.


I was told for someone who does not intubate at least twice a month it is illegal to do so.  I have had babies who needed resuscitation however the paramedics did the intubating. Forceps?  My neck would be on the chopping block for that one.




Non-Medical Forms (Confirmation of Appointment/Pregnancy/Return To Work/Work Restrictions)



Our office has 4 pre-printed forms, on 8 1/2" by 5 1/2" (1/2 of sheet of standard typing paper); each of these has our office letterhead across the top, so it looks "official", and is on NCR paper; we give the client the original and keep the copy in her chart.

All the forms have a space for the date at the top, and our signature at the bottom. The 4 forms are:

We used to just hand write this out, on Rx pads, but this is SO much more time-efficient, and looks more official.


Birthing Rights



See also:  Homebirth Advocacy


Absolute Right to Homebirth in the UK

In the UK, it is written in our Midwives Rules and in law that we MUST attend women in birth - wherever that be, and however suitable for home birth.  GPs do not have the same statutory obligation.


Court-Ordered Care — A Complication of Pregnancy to Avoid
Julie D. Cantor, M.D., J.D.
N Engl J Med 2012; 366:2237-2240June 14, 2012

What ARE “Our Rights” in Childbirth? By Susan Hodges [Citizens for Midwifery News Fall 2008]


Pregnant Woman Ordered To Undergo Involuntary Medical Treatment - In an amicus brief filed today, the ACLU took on the State of Florida's decision to order a pregnant woman to remain hospitalized indefinitely, and against her will.  Samantha Burton, already a mother of two children, developed complications in her third pregnancy.

ACLU's Amicus Brief


New York - Class Action Suit for Homebirth Rights


Abby Odam and Birthing Rights in California


Even if home-births ( in low risk women ) were less safe than hospital births ( which they aren't ! ) then it is still a matter of choice.

As a gynaecologist I see lots of women with heavy periods despite medical treatment. Many of them opt for surgical treatment - rather than the other option of putting up with the nuisance until the menopause. Now it's widely known that just occasionally a woman dies after routine gynae surgery ( very rare fortunately ). No-one ever dies from heavy periods. Don't all these women ( and their ob/gyns ) realise that avoiding surgery would be overwhelmingly the safer option ? Actually the women and their MDs simply make an informed choice about quality of life - and there's nothing wrong with that - no matter what the context.


There are some people that have some serious concerns about the recent decision in CA about midwifery. There is a major distinction between misdemeanors and felonies in the CA law. If anyone dies during the commission of a felony, whether the deceased is called the victim, a bystander or even a perpetrator, whoever is convicted of that felony is also guilty of felony murder.

The constitution of the United States requires laws to be made in the Congress. The Court's function is to interpret these laws. California has historically used the courts to usurp the powers of Congress by making law through judgments or precedents.

Midwives be advised regardless of the recent licensing laws in the state of California, this recent court decision has made the practice of midwifery illegal. It is now more illegal then it was before. 


Discussion of Birthing Rights



Lawsuits and Complaints



Keys to minimizing liability in obstetrics By Gary Ventolini, MD, Christopher S. Croom, MD, and William W. Hurd, MD



Doctors-Turned-Lawyers: Why We Now Sue You - What Not to Do if Things Go Wrong

Condylomas Lawsuit


Lawsuits and Complaints


Cesarean Lawsuit Won by Patient

June 17, 1993 Wall Street Journal

Caesarean Birth Verdict

A jury has awarded more than $1.5 million to a woman who sued her doctors, claiming that the unnecessarily delivered her child by caesarean section.

The verdict is unusual, lawyers say, because while malpractice cases are often filed in cases in which a mother or child is injured because doctors failed to do caesarean surgery, patients rarely sue on the grounds that a caesarean wasn't necessary.

In the case, which was filed in Cambridge, Mass., the woman, Mary Measdor, developed an intestinal illness which she said was triggered by the caesarean delivery. Her doctors, Stanley Stahler and Ruben Gheridian, said that she had consented to the procedure.


Suffering, not malpractice, guides medical suits


Case Dismissed - Hopes for Appeal


Don't you realize that all of us live in the daily fear of getting sued or arrested for just trying to do a good job?
It bothers me to hear about any midwife having legal problems.

But it bothers me even more to think that it's possible that a midwife might actually have done the things the they are alleging. And it's somewhat unsettling to realize that some people think they shouldn't make a fuss about their perception that they were grossly mistreated and have suffered real damages from unnecessary surgery.

I spend a great deal of time on lists run by/for birthing parents - the ICAN list and the homebirth list.

There are a lot of unhappy folks out there, and a reasonable share of them have complaints about midwives. Appalling as it seems, there do appear to be midwives who do not always provide the best possible level of care.

It really isn't enough just to try to do a good job, in the sense of wanting the best for the clients. We actually have to come through anddo a good job, even when that means providing a referral or calling in backup.

I would like to think that all midwives come from a place of good heart about their work and are dedicated to providing the best possible care for the families they serve. And the times when I see midwives fall short of their own objectives are usually times when the midwife ran short on time and/or energy.

It sounds as if this might be what happened in the their case; a midwife with an unreasonable case load behaving in ways that maybe aren't in the clients' best interests.

Is it really such a bad thing for each of us to take this opportunity for some introspection?

Are you making commitments you can't keep? Do you have good midwife backup? Do you reduce your caseloads when a partner is on vacation? If not, do you let your clients know that this may compromise their care? Do you solicit feedback from clients after their last appointment or do you just assume that everything must be fine if they didn't complain?

And, most importantly of all, are you being absolutely honest with your clients about what kind of care you are offering?

I have absolute tolerance for any and all styles of midwifery practice that are made clear to the clients.

I won't criticize a midwife who tells her clients at 40 weeks that they either have to agree to a pit induction or have their care transferred to an OB, as long as this possibility was made clear to the clients.

And I won't criticize a midwife who doesn't try to change a posterior or asynclitic head, as long as she makes her style of practice clear to the clients beforehand.

I don't care whether a midwife goes strictly by the book or hasn't cracked a book in years, as long as this is made clear to her clients.

But it galls me that there are midwives who hide behind the veil of purity and expect that having answered the sacred call of midwifery somehow puts them on a pedestal above criticism, regardless of how they may have misrepresented the kind of care their clients can expect.

I suggest that you look within and relax and be thankful that you have a baby to love and nurture (you don't write much about that) and redirect your passion.
This sounds like a rather sweeping assertion that anybody who survives a birth with a live baby should have no complaints. Yes, it could have been worse, but it could also have been a whole lot better.

Some of this week's discussion on the ICAN list has been about the very deep loss that they feel around their birth experiences, "even with a live baby". Many of them feel deeply wronged, and I agree that most of them received lousy care and have a lot to be angry and sad about. I'm one of those who happen to think that they have an obligation to themselves and to their families to process these feelings, rather than simply "getting on with their lives", which really means suppressing their feelings.

Hearing you telling them to put it behind them sounds a little like telling parents who've lost a baby that they should be happy because they still have healthy ones at home and/or can still have more babies.

Gosh, why is it so hard to accept that some people have really horrible birth experiences, and some of the caregivers involved might have been midwives?

There have been times when I have not provided the best possible care to my clients. Given that I'm a relatively new midwife, these have been from lack of experience rather than lack of time or energy. But I am crystal clear with prospective clients about my training and experience, and I tell them that I cannot "play the edge" the way a more experienced midwife might. And I have done my share of apologizing to clients when I've been wrong.

I have never knowingly lied to clients to CMA, and I hope and pray that Grace will provide me with the strength to keep that true.

And if the fear of betraying my own integrity and my very serious obligations to my clients isn't enough to make me do my very best, then let it be the fear of arrests and lawsuits.

Any attack on ANY midwife is an attack against ALL of us and we cannot pass judgment on her actions as we WERE NOT THERE.
I agree that we cannot pass judgment on a particular case about which we do not know the facts.

But I do not believe that I have a responsibility to provide blanket support for everything that is said and done by someone just because she is a midwife. In fact, I believe that I have an obligation to condemn mistreatment by any care provider, regardless of what they call themselves. And I hereby openly condemn any care provider who recommends unnecessary surgery simply because they do not have the time, energy or patience for the situation at hand. This is no more acceptable from a midwife who is exhausted than from an obstetrician who wants to make his tee-time, although it may be more forgivable.

We, the midwives, are supposed to be serving them, not the other way around.


I know how easy it is to 'fall into planning and arranging care to fit the schedule-of docs, nurses, hospital, myself'. I did that soon after getting out of school, and when i became conscious of it I was so appalled, cuz I had previously consciously thought i would never do that.



Comment on Ethics from an OB



You do what is best for the patient, not what you think will look best to a plantiff's attorney. If you think something is best for the patient and you delay because of malpractice concerns, then you are acting for your own interests and against the patient's interests, and the only word for that is "unethical."



CLIA and Waived Tests



Complexity by Method (from The Clinical Laboratory Improvement Act (CLIA) and the Physician's Office Laboratory: Introduction)


CLIA Waived Test List - updated 02/02/2000 - from the Public Health Practice Program Office at the CDC


CLIA is Clinical Laboratory Improvement Act. Each medical facility of any kind that does any blood or urine testing is supposed to be listed with CLIA. The purpose of CLIA is to keep labs on the up and up. You have to be trained to run tests properly and you have to have a medical director who oversees the operation of laboratory testing. If you think about this, it is a good idea. Suppose a docs office (or one of the rich midwives!!!) hires some teenager to come in and run their gestational diabetes testing for them. They are shown the machine and told here's the book, do the testing. This kids messes up and everyone has GD and is treated with insulin. This happened here in Arkansas at the HD with hemoglobin testing with the hemoglobinometer. The nurse got a 9 on a kid's Hg and sent her to the doc. The doc sent the kids back with a 14. They drew blood and the Hg was 14. A real embarrassment to the HD and a possibility for suit.

Back to the topic at hand. So the government comes up with this CLIA thing and here in Arkansas the Health Department sent out a letter to all the midwives saying that we were to be CLIA certified also. And yes, you could get into trouble if you aren't registered with the government. But how are they going to find you.

I've had a CLIA certificate for about 5 years now.

All the tests that we actually run are called "waived tests". Only labs or big offices actually do any of their own testing any more. Collecting the specimen and sending it to the lab does not count. Running the test is what is monitored.

Waived tests include urinalysis for the things we check for, Hg, Bg, etc. Any dip stick tests and any machines that spit out the answer. With the hemoglobinometer, you are making a judgment call and thus they think it is not a waived test. The Hemacue since it gives you the results like the Accucheck does is considered waived. No room for human error, supposedly.

But the problem is that the Hemacue as I understand it costs about $600 or something like that. Enough that I never checked into it. My hemoglobinometer may not be that accurate but I use it anyway.

I would think that all state licensed midwives would all have to have a CLIA certificate. It basically states that you do not run other tests besides the waived tests. To get a certificate to run higher classed tests can cost up to $10,000.

I think the next level up from waived tests costs $1000. These are fees for every 2 years.


Any time you do any laboratory testing of any kind you are supposed to be registered with CLIA. That includes urinalysis such as we do. It also includes Hg, Bg, etc. These are all waived tests. Don't require too much expertise.

To do microscope tests, other more specialized, you are supposed to be properly trained so as to get accurate results. CLIA was begun to regulate laboratories so as to get accuracy in testing. But CLIA has made doctors offices have to stop doing testing even. There are so many regulations and inspections to deal with. And the fee for advanced testing can run into the tens of thousands. I pay $100 every two years to have a waiver for the easy testing.



Physician Backup




May 11, 2011 — In a joint statement, the American College of Nurse-Midwives (ACNM) and the American College of Obstetricians and Gynecologists (ACOG) called for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives.



How have you been able to initially contact and TALK to OB/GYN's about being your consulting/collaborating physicians? And how have you formalized that agreement?

My dilemma is two-fold. I am a new graduate nurse -midwife and in my state- Arizona- I need to have a physician listed on my application for a state license as my "official" collaborating physician. I have sent out resumes (Unsolicited "cold calls") to every OB in the area who I would be willing to work with, and have made follow-up calls with little results. I can't even seem to talk to them on the phone, let alone set a time to meet with any. They are either out of the office, seeing pts, doing procedures or......you get the picture. I am thinking that the letters and resumes are being screened by the office manager and/or nurses in the office so the docs may not even know about me. I work full time +, and can't afford to sit in offices on the chance that maybe I can have an impromptu meeting- plus it would be impractical....

Any suggestions?


Ask them out to lunch


Would someone please clarify the legal authority under which a midwife is licensed to practice without medically approved protocol and physician back-up in any of the states in the U.S.? This assumes that there is a relationship that involves charges for services.


In Maine, the Medical Practice Act specifically excludes vaginal delivery from being defined as a medical procedure. There are both nurse midwives and lay midwives practicing throughout the state doing home deliveries. We have a fairly cordial relationship with the lay midwife in our county because we decided long ago that an adversarial relationship would only interfere with care of her patients who needed hospitalization. I haven't heard of any breech home births in our area but I do know of several VBACs. When I mentioned to the midwife that I didn't consider VBACs low risk and suitable for home delivery she sent me the A.C.O.G. literature touting its safety. Hoisted by my own petard!


My partner and I are the only CNMs doing homebirths in this state. Both of us were direct-entry midwives before becoming CNMs. So we both were ingrained in OOH birthing. I have a birth ctr, so we do birth ctr and home births. Contacted, met with a group of OBs about being our "back-ups". We asked for a lot at the beginning -- i.e. chart review, etc. Worked out what they were willing to do after they consulted with their malpractice insurance co. and attorney. What we ended up with in writing is a letter stating they will accept our clients if transferred to the hospital. Not much different than they do for any other walk-in. That's what we have in writing, and what I use whenever written confirmation of back-up is needed.

In reality, these 4-5 OBs have been very helpful and respectful r/t consultations, referrals, transports, etc. I guess that they just can't have a formal, written agreement d/t liability issues. But they know what we had wanted and asked for at the beginning -- more of their input towards our practice (which we didn't necessarily truly want, but showed our intent to work with them). One of these OBs is always on call, so have had no problem with transports, etc. Anchorage is overrun with OB practitioners -- OBs, CNMs, DEMs, perinatologists. So perhaps they just want our business, that's okay. This group has 5 CNMs working with them so they already are pretty much midwife friendly.

We don't have hospital privileges either at this time. Difficult to find an OB to sign as preceptor for an independent midwife. The preceptor form at both hospitals here state, "I will be totally responsible for this CNM morally, ethically, and financially." Hard to even sign such a statement for your own kin! Had tried to get the bylaws changed at one of the hospitals, it was shot down by the perinatologists, OBs. I'm sure a lot of it is because of the high competition for clients at this time here -- comes down to reduction of income for them if they let those independent midwives in the hospital too!


I think you're right - it IS more difficult to be a CNM in homebirth practice because of physician opposition. We are educated within the medical system and are supposed to function within the medical system, and that works as long as we do what we're told by the powers-that-be. When some of us want to do homebirths, or even independent practice with hospital births, it can get pretty sticky pretty fast.

There are no doctors in this area who will "back" me for doing homebirths, which was a major obstacle at first. I even called the ACNM to find out exactly what it means to have a "arrangement" (or whatever word is used) with physicians - does it have to written, how informal can it be, at what point do I get into trouble, etc. The answer I got is that it depends, but basically there must be some avenue to get more specialized, intensive care for clients who become high-risk. In this area, I know the docs and nurses because I've done hospital births here for seven years prior to starting a homebirth practice. That was a big advantage for me because I knew what they thought:

  1. they wish no one was doing or having homebirths
  2. and if they can't make it stop, then at least they want someone who knows the "rules" (i.e. someone they know will make appropriate referrals); and
  3. the last option that they just hate - having an "earth-mama" no-interventions midwife do the homebirths and leave messes for them to clean up at the ER door.
In the whole scheme of things, having me out there doing homebirths seems like the lesser of the evils, so they haven't shown any direct opposition to what I'm doing. Of course, they absolutely will not condone or support what I'm doing, either. So I decided that I would approach them with the fact that if I'm doing homebirths safely, they WILL invariably seem some transfers and consultations, and to make things as easy as possible for them, what were their preferences as to how I should go about that? I spelled out options in writing, they checked off what they wanted, and bingo, I have consultative arrangements. I haven't needed a lot of physician input into my practice in the last couple of years, but when I have, they have been pretty good with me and respectful to my clients.

It may be that this works only because I'm in a smaller town where there are only 6 OB/gyns split between 2 groups/hospitals. All I know is that despite my fears and the dire predictions of others about the possible success of starting my own homebirth practice, I've managed to do it. And I think already having a reputation within the medical community has helped. The docs have lots of liability concerns about being responsible for what I do (which is why I'm no longer employed by them), but seem to have little beef with me doing my own thing (as long as I don't take too many of their clients, I'm sure).

The problem is that I had to relinquish my hospital privileges since I don't have a physician "sponsor" - someday I'll work on changing the bylaws to something more workable for me. I do have outpatient privileges, though, so can order labs, sonos, NSTs, etc.


I don't know that "supervise" is the best word to use, at least in my state. In Montana, a CNM is an independent provider. Collaborative relationship might be a better term to describe the relationship between the CNM and MD.



I have heard the phrase "midwife-directed physician-patient consultation" to refer to the episodes of care when a midwife's client has an appointment with an OB.

"Supervise" is definitely the word here in California. The laws for CNMs and DEMs both state that the midwife works "under the supervision" of a physician. We dream of being recognized as independent providers.

Actually, we do more than dream, we're trying to change the language of the laws. Our bill got killed last year, but we'll be back!


My partner and I are currently negotiating with a group of OBs to sign as our preceptors to obtain hospital privileges.  Their biggest worry at this time is that they would have to do chart review for us.  They have been backing us up for 4 years on our home and birth ctr births.  But to sign on the dotted line for privileges is another matter.  In the past they have done backup for nothing, but got all our referrals to the hospital.


I have a letter from my consulting OB that states that he has "agreed to accept referrals and consultations" from me.  It satisfied my hospital requirements.  He is only responsible for the actions he takes, not for my actions.  Our Family Practice docs essentially have the same requirement for OB patients.


Letter to Doctors Requesting Backup



State-by-State Supervision/Collaboration Issues



This is a new section - please e-mail me information about your state if it's useful here.  Thanks.


California Bill SB255 Fails to Change "Supervision" to "Collaboration"


Colorado does not require supervision but the instances are spelled out for when we need to consult.  Our rules are in  serious need of updating.



Homebirth Backup Physician Useless in Emergency



When I had an emergency transport with my first homebirth, I was just stuck with the doctor on call because according to law my midwife has to transfer me to the nearest hospital capable of handling my "emergency" so her back-up doctor didn't really do me any good.

My midwife does have an MD who is her back-up, but unfortunately, he practices in a town not very convenient to most of us in the metroplex, so although she can consult with him about various things, he rarely would be "available" to take over a delivery that had to be transferred, due to his location/hospital privileges being not the "nearest."



Physician Harassment



After I transported a VBAC client into the local hospital, the receiving OB took me aside and raked me over the coals.  He said if he ever heard of me doing another VBAC he would put me in jail.  He said he was supportive of homebirth and that he would even do it himself if he could.  He said 99% of women are safe to birth at home, then he even said that I could do a 2nd or 3rd etc. VBAC, but not a first-timer.  He said he would find me- I couldn't hide.


I would send him a letter confirming that was what you heard of your conversation.  I would have a place for him to sign his name and to return the letter to you for your records.  I would consult a lawyer for harassment and notify him that he is no longer allowed to THREATEN you for being a good and caring citizen.  Don't let some fearful and VIOLENT man prevent you from doing what you know in your heart is right.



Hospital Privileges



How does an independent practitioner actually go about obtaining hospital privileges?


Here in Oregon a CNM calls the medical staff office of the hospital and requests an application.  The response will include all the requirements. These may include your CV, evidence of malpractice insurance, a documented affiliation with an OB/Gyn for high risk consultation and surgical services, letters of reference.  Then the application and documentation will go through all the hospital committees which usually only meet once a month so the process will take at least about 6 weeks.  Unless this is a totally new entity at the hospital.  In our case it took 10 months to change the necessary policies in regard to affiliate medical staff status.  If your hospital has nurse anesthetists with privileges check out the rules and regs that apply to them.  Medical Staff Office is the place to have friends and start investigating.  There is a hospital here in Eugene that restrains the trade of midwifery practice by requiring employment by physician or hospital to be on staff.  Be persistent, positive, and friendly.



Malpractice Insurance



See also: Asset Protection


EIB - Evolution Insurance Brokers - Professional liability insurance for birthing industry professionals.  877-678-7342 x3715
Coverage for birth centers, nurse midwives, direct-entry midwives, students, doulas, consultants, suppliers, homebirths and more.


October, 2009
Subject: Malpractice Insurance Coverage for CPM's and LM's

NEWS RELEASE
Contemporary Insurance Services is pleased to announce the immediate availability of Malpractice Insurance coverage for Certified Professional Midwives and Licensed Midwives practicing in states that license these professionals.  Contemporary Insurance Services has over a decade of experience providing medical malpractice insurance coverage to Certified Nurse Midwives through its Healthcare Professionals Risk Purchasing Group.  The new program for CPM's and LM's offers coverage for home, birth center and hospital births.  For additional information contact Israel Teitelbaum, President, at 301 933-3373 or 1 800 658-8943 or click on "Midwife Free Quote"  at www.cisinsurance. com.
--
Israel Teitelbaum
President
Contemporary Insurance Services, Inc.
11301 Amherst Avenue, Suite 202
Silver Spring, Maryland 20902
301 933-3373
1-800-658-8943
Fax 301 933-3651


You need to be careful with this-make sure you will still be covered if you don't have 'physician supervision.'?  When I spoke to another insurance agent at a midwifery conference (Rick Linsey with CIS), he said they would cover us as long as we practiced by our licensing guidelines. I told him the law states we must have physician supervision.   I told him even if we do have a physician who will take our transports, we don't all have written back up agreements.  He said he would look into it and never got back to me.  I'm sure they will take our money, but make sure they will actually pay for a claim or represent you if you don't have 'proper' backup agreements.


Issues and Allegations: Medical Malpractice - A nice overview of the issues from The American Voice 2004


American College of Domiciliary Midwives - Community Midwives Malpractice Insurance Consortium


Courts Rule Against Increased Malpractice for OBs working with Midwives


Why Midwives Don't Get Sued


MALPRACTICE INSURANCE Midwifery Insurance Program
Endorsed by Unisource Insurance Company
Call or Write Today
Dean Insurance Agency, Inc.
Ann A. Geisler, CPCU
PO Box 3268
Orlando, Florida 32802
800-721-3326

Available in Florida Low cost - not based on the number of births you do. It covers home, birth center and hospital births. Their research said we were a safe risk :-)


Has anyone practiced bare and then obtained insurance? I am running into a problem with my consulting physician's insurance company and their unwillingness to issue her vicarious liability because of a perceived risk if there is a claim made from the time I was bare.


Why is the doc getting vicarious liability? Has new info come out since Susan Jenkins the ACNM lawyer wrote the article "the myth of vicarious liability"?


Her carrier is requiring that she have vicarious liability in order for me to work for her. They will not issue it unless I can get coverage for my practice during the time I was bare (1985-1998). Of course, no insurance company wants to provide coverage retroactively #1, and #2, I was a licensed midwife not a CNM, and there was no coverage available. (I have been a CNM for 6 months). Her company is claiming that even if they are not insuring me, if I am working for her and someone I delivered say 8 years ago decides to sue me, she would be liable since I am her employee! Any advice most welcome. They have said they would not issue coverage until the youngest baby was 21 that I delivered bare. The Doc says, well it's just such an unusual situation. I say no, there are hundreds of midwives who have done homebirths bare and then been able to go on and work for Dr.'s. So help me. Share your stories. Perhaps they will help the insurance company see the light!


This really makes no sense.  Why would this MD be responsible for births you did before you were involved with each other?  I don't see how there would be any way someone could sue you for a birth many years ago and be able to name this MD as anything to do with it!  I mean, it seems it would be easy to prove that you had nothing to do with each other at that time.

I was a direct-entry midwife for many years before I became a CNM.  None of the OBs that we have talked with have ever mentioned coverage for births prior to when they became involved.  We are negotiating with a group now.  We currently do homebirths.  They said that if they sign as our preceptors in order to get hospital privileges that giving up homebirths may be a condition.  They never mentioned any tail coverage for these past births.  We have never had malpractice ins for homebirths, only for birth ctr ones (costs twice as much to cover the homebirths!).


Oh this type of coercion makes me so upset! I have a homebirth practice and have been working at changing the bylaws at the only hospital in the county, it was in the lawyer's hands last I looked at it, and is to be/ or should be by now independent hospital privileges, but I live 40 miles from the hospital, and they demand within 20 minutes or have someone on call for you.


I was told by the ACNM Ins co. that a CNM can attend both home and hosp births, but only the hospital births will be covered by the malpractice ins. There is an option through another co that will cover home birth, but the cost is VERY unreasonable.


CNM's and other practitioners do need malpractice ins to have hospital privileges, at least in AZ.



About Being Investigated



Recently I was told you are suppose to ask the caller if they are an investigator or do you work for the health dept? something to that effect- they aren't supposed to lie if asked directly. ( sort of the hooker approach- these older professions you know ; ))

When I practiced illegally I lived in a state where it WAS NOT a felony and no one had ever been convicted. Many of the openly practicing MWs had gotten c&d letters few took it to heart. The state just didn't have the funding nor the volition to get hard core about us. So this is definitely not your situation, if the AMA has targeted your state, they have probably lobbied for some sort of investigative funding... if the labs have cut you off , how about sending away, or a friendly doc, naturopath , chiropractor? If they order labs this is legal for them to do, and you can get a copy.

The way I've seen it done is to figure out what the letter of the law is then figure out what it doesn't include. Practice in the loop-holes, still could be dangerous but often dependable. What does your lawyer suggest?


The first rule for apprentices and midwives: DO NOT TALK TO ANY AUTHORITIES! DO NOT EVER AGREE TO AN "INTERVIEW"! DO NOT TALK TO ANY PERSON ABOUT ANY CRIMINAL MATTER WITHOUT ANY ATTORNEY PRESENT!

We've had a few cases over the years in our region. Every single time (to the best of my knowledge), any person who agreed to an "interview" was charged, or "had to" turn evidence through fear of being charged.

Any time an interview was refused...... nuthin' ever happened.

Ya DON'T talk to any government agent when they're going on a fishing expedition!

They can seem so nice and charming and harmless. But that's their job! to SEEM to be friendly and to get us to trust them, and to talk to them. And anything we say can be twisted into something which harms US!



Legal Strategies



Strategy for Fighting Charges

I wrote a letter to the BRN and enclosed a press release and the addresses of 200 radio stations, newspapers and television stations that I was sending this release out to. Just to inform them that it was going out on the eve of my final hearing.

The hearing was canceled and eventually all the charges were dropped.


Encouragement and Moral Support for Midwives Under Siege

Also read What Do Trees Have To Do With Peace? - the story of Dr. Wangari Maathai, the 2004 Nobel Peace PrizeLaureate.


There's a great article - Midwifery is not the practice of medicine by Suzanne Hope Suarez, in the Yale Journal of Law and Feminism, Vol 5, No 2, Spring '93.


NARM Position Paper on the Practice of Midwifery - "The practice of midwifery is a distinctly separate profession from the practice of medicine or nursing."


About Homebirth Legal Battles


More Legal Strategy



Specific Country/State/Personal Situations



Midwifery Today has a Forum on Legal Battles and Birth Politics


A Battle for Body and Soul by Carolyne Pion - about Karen Hunter, a Maryland midwife, arrested in 2002 or 2003 for a birth in 1994 and about legal discrimination against homebirth.



I'm sure many of you remember hearing about midwife Katie McCall, or even donating to her cause.  Katie was unjustly prosecuted by the California medical board last year, after they had licensed her, for practicing medicine without a license while she was a student.  She has written her story and it's available for pre-order. 

"Katie McCall went from being a mother of two and professional midwife, to homeless single mother and convicted felon, at the whim of people she'd never met, who decided from within their cubicles that she needed to be punished. Let her cautionary tale show you how easy it is to fall victim to the tyrrany of the cubicle."

The Tyranny of the Cubicle by Katie McCall

[NOTE - What would *you* do if you were a doula or a student assisting a woman at a homebirth when the woman suddenly starts pushing, and the midwife hasn't arrived yet?  I think we can all agree that informed consent is very important for the family, who may not understand the limitations of a doula or a student.  You might be sure to say to the family, "I'm not equipped to provide medical care.  Do you want me to call 911?"  They can always decline treatment from EMS, but if they're available to help resuscitate a baby in trouble, that could be life saving, and that's a decision to leave to the family.

A Current Summary of Breastfeeding Legislation in the U.S. - a state-by-state guide to breastfeeding laws in the U.S. from La Leche League.


Text of Adopted Decision in case against California Licensed Midwife Alison Osborn Administrative Law Judge dismissed charges after extensive hearing (August 20, 1999).

Amicus brief filed by California Citizens for Health Freedom

Amicus brief filed by California Citizens for Health Freedom


In Denmark it's any woman's right to give midwife-assisted birth at home. She cannot be refused, irrespective of whether she has refused the routine datings or not. Midwives/doctors will probably try to persuade/recommend her to go to the hospital - and may also "label" her a high-risk. But the woman has the law on her side. The recent 20 years I think, the home-birth rate in DK has been 1-2 %.


European Cases Against Midwives - from Sheila Kitzinger's site


Debra O'Conner, CNM, in Washington State (January, 2002)


Kellie Sparkman in Nevada (March, 1999)


Maternal Death in North Stafford, Virginia - midwife Cynthia Caillagh (late 1998)
Virginia Birthing Freedom


Amy Medwin - North Carolina


Seeking information about maternal death at El Camino Hospital in Mountain View, California in 1997 or 1998, thought to be from a post-cesarean infection. Please e-mail any information.  Thanks.


MANA's Guide - Direct-Entry Midwifery State Legal Status as of 9/96.


Motherstuff - Midwifery-Related Law


California's Licensed Midwifery Practice Act of 1993 - Also see Notes for California Licensed Midwives


Citizens For Midwifery - State By State


Current midwifery battles in U.S. Courts.


Illinois Midwives Homepage (re: 1997 legal situation)


A Mother's Letter to Illinois Gov Edgar


Minnesota Families for Midwifery


M.A.N.Y. (Midwives Alliance of New York)


New York Legal Situation


New York - Class Action Suit for Homebirth Rights


NY Update 5/16/97.


5/31/97 Update on New York Class Action Suit


5/31/97 Update on New York Class Action Suit - Morning Session


Martha Hughes - Midwife Prosecuted for Breech Death


Beah Haber - Midwife Lost Privileges at  Valley Care Center in Pleasanton, California.


The Boots at the Door
Editorial Comment by Ina May Gaskin (1994) about the arrests of Lynn Amin, CNM, Beverley Thorpe, CNM, and Lorri Walker, RNP for their work at their Natural Birthing Services birth center in Southern California.


Abby Odam and Birthing Rights in California


California Bill SB255 Fails to Change "Supervision" to "Collaboration" for CNMs


Midwife Leaves Illinois After Legal Harassment


Kansas Court Proclaims DEMs Legal


Entire Ruling of the Kansas Supreme Court re: midwifery


Bloomington Indiana Midwife - Jennifer Williams, CPM

Indiana Prosecution

Indiana Midwifery Taskforce

Midwife’s arrest protested [1/16/06] - Indiana has brought felony charges against long-time midwife and CPM Jennifer Williams for practicing medicine without a license and practicing midwifery without a license in Shelby County, Indiana. After 17 years of practice without incident, she was brought to the attention of authorities because of a stillbirth, and after an investigation, was found to have acted appropriately both in the delivery and her response to the emergency.   (Please note that the news account has some inaccuracies – for one thing, the baby died of asphyxia, ie, was stillborn; any cephalhematoma was incidental, and the midwife does not own and never used a vacuum extractor.)  The parents are completely supportive of their midwife.


Midwifery Legal (in Michigan?) - Not the Practice of Medicine

Because of an attorney general's decision in 1939 that midwifery was not the practice of medicine, midwifery is still legal to practice here. 

Midwifery Persecuted in New York State


Roberta Devers-Scott Sued in 2005 - A former Mendon (VT) midwife and one of her students is being sued by a woman who claims that her 21-month-old son suffered permanent brain damage during birth.


Press Release regarding Citizen Support for Roberta Devers-Scott


Roberta Devers-Scott's Court Statement in response to Misdemeanor Charges 9/23/96


Women In Wisconsin May Lose Civil Rights During Pregnancy



Records Release Forms



Medical Records Release Forms in both .pdf format and .doc format, which you could tailor.



Release from Care



Don Self's web pages has a sample form for "divorcing" a client from your practice.


Terminating a Patient: Is It Time to Part Ways? [09/20/2005] by Deanna R. Willis, MD, MBA; Ann Zerr, MD [Medscape registration is free.]

Sample Termination Letter

When you decide to end your relationship with a patient, inform him or her in writing and send the letter by certified mail, with a return receipt requested. If it's possible to describe the reason for the termination in a brief, clear, objective way, do so in the letter. If not, you might be better off not providing a reason. The patient ought to be aware of the reason as a result of earlier discussions and correspondence. Some malpractice insurance carriers offer sample termination letters, or you can adapt the following sample.

Dear [patient name],

As you know, a good relationship between a physician and his or her patient is essential for quality medical care. There are times when this relationship is no longer effective and the physician finds it necessary to ask the patient to select another physician.

This letter is to inform you that I am no longer willing to be your primary care physician. The reason for this decision is [describe reason briefly, or omit this sentence]. Our office will continue to direct your care for any emergencies that arise over the next 30 days. It is imperative that you select another physician and arrange with our office for your records to be sent to your new physician before [date]. Your insurance plan or the local medical society [insert contact information] will be able to assist you in choosing a new physician.

Sincerely,
[Physician's name]


I sent a pt a divorce letter and a refund check via certified mail. She knew we were sending her a refund because we spoke with her the day prior and told her how much she would receive. She refused the certified mail and my question is: What do we do now as far as divorcing her and do we still owe her a refund?


If the letter that is sent via regular mail (be sure to document that you sent these this way when the certified letter was refused) does not come back AND when the canceled refund check comes back, you can safely assume that she received the letter.


You may want to check with your attorney, but usually, if you send one certified and one at the same time, regular mail, it's considered "fair notice".  Put the refused certified receipt, uncashed check and copy of letter you sent in her file and then forget about it.  If you haven't sent one regular mail - go ahead and do it and then honor that letter - whatever it says.


As far as the refund, was it an overpayment, or were you refunding simply because you are divorcing her?  An overpayment you still owe, but I never believe in giving money back just to shut people up.  As far as the letter goes, if certified mail is refused I send the letter in a plain envelope with just the street address as a return, so they don't know who it is from before the open it.  You can't be positive that they received it, but if it doesn't come back you can be pretty sure.


Letter for Release of Care

Sometimes you have clients who mysteriously disappear, cancel or miss appointments, don't return calls, etc.

I would write them a letter telling them, in detail what Midwifery care is all about, i.e.: Shared responsibility, etc., and that since they have not held up to their end of the agreement, that the relationship is terminated.  Also be sure to give referrals.  I always make sure that I give names and numbers to DEM's, CPM's, CNM's and OB's.  This covers some pretty good ground.  Here is a sample of something I might send IF I was going to give her ONE MORE CHANCE, which I doubt I would at this point.

I as a midwife believe that prenatal care is an important part of a healthy pregnancy and happy, successful birth experience.  Since first meeting you we have only had one prenatal visit which is not adequate for establishing a midwife-client relationship.  If I do not hear from you in the next week, I will assume that you have sought care elsewhere.

If however you do wish to continue care with me, the following will be necessary.

    1. Regular and timely prenatal visits for the remainder of your pregnancy.
    2. Payment of (insert dollar amount here) by (insert date) as previously outlined.
I hope that your pregnancy is going smoothly and wish you the best of luck with whomever you choose for your care.


Dear Ex-Client:

A physician may terminate his or her relationship with a patient for any reason including failure to follow physician orders which leads the physicians to believe that this relationship should not continue.

Therefore, we are enclosing your records and advising you to seek alternative care. We will, of course, be available to you if an emergency arises and emergency care remains available through the hospital emergency department. We will terminate any and all further treatment and/or care of you as of <date>.

Sincerely,
<provider>


She is showing great irresponsibility and you will bear the brunt of ANYTHING that goes wrong.  Send her a certified, return receipt requested letter of release.  Include in the letter several alternative caregivers ( doctors in the area, county hospital clinics, etc.) and let her know you WILL NOT attend her birth.  If she calls you in labor, remind her of your letter and call 911 to go to her house.  This will keep you from being accused of abandonment.  These cases are NOT WORTH IT!!



Charting



Documentation Do's and Don't's - an online CEU course.


Charting from Midwifery Today's E-News


Great chapter about Labour Admission and Partogram (Hlth1583) from the British Columbia Reproductive Care Program.


Documentation about Shoulder Dystocia is a good case in point lesson about charting.


For the labor/delivery records:  I want to know what position the client is in and where she is at all times on the chart.  I want the chart to tell you the exact story of the birth and I do want to know what heart tones are q 15-20 minutes during most of active labor and q 5 minutes during 2nd stage.  There is also always a heart tone check after ROM unless baby follows the water out.



Miscellaneous Legal



Accused of Practicing Midwifery on Herself

Darjee Sahala bravely gave birth to her first baby, Brona Sahala, who was born still.  Six weeks later, she found out that the OB that caught Brona, Lisa Jamroz (Boulder Community Hospital) and her group sent a complaint to the state about Darjee as a midwife and that because of it, Darjee was under investigation for practicing midwifery without a license . . . on HERSELF, even though she had several professional midwives caring for her.  The investigation was dropped a couple of months later because it was so ridiculous, but only after Darjee had to spend $$$$ on a lawyer and tell the state the story of her birth.  [I encourage you to watch the beautiful slideshow about Brona and then another beautiful slideshow about Imara's joyful birth.]

The State vs. Midwives: A Battle for Body and Soul by Carolyne Pion


California Law - Midwife Payment Through Preferred Provider


Malicious Gossip

Q: What do I do about some other midwives spreading untrue rumors about my practice?

A: Send a ‘friendly’ letter TIAing whomever to ‘cease and desist’ from making any further libelous/slanderous comments directed toward your professional entity?

 




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