On April 29, 2016 the Maine Legislature overrode the Governor’s veto of LD 690, “An Act to Ensure the Safety of Homebirth” with overwhelming bipartisan support in both houses. This bill will regulate the practice of CPMs and CMs in the state of Maine. That’s the very happy end of a very long story of negotiation, collaboration, compromise and a lot of hard work—a story I will try to retell here.
Being a rural state that is not on the way to anywhere, Maine has maintained a strong and continuous tradition of home and birth center birth. Maine’s independent Yankee spirit and appreciation for the natural world lends itself well to normal physiological birth so it is not uncommon to find, when chatting with the older generation of Mainers, that they had been born at home or in the local birthing home with a midwife or the community physician. Approximately 2% of all Maine births occur outside the hospital, mostly at home with a CPM in attendance.
The midwives began to discuss pursuing a license for CPMs in the 1990’s with quite a bit of resistance from many of the practicing CPMs. Since the organization of midwives, Midwives of Maine, worked by consensus, the discussion continued over many years until no blocking concerns lingered, although support for licensure was not strong in the group. A new organization, Maine Association of Certified Professional Midwives (MACPM) was formed specifically to work towards legislation to license CPMs in 2005. The first MACPM initiated bill was introduced to the Maine legislature in 2007.
This bill was not negotiated with any other stakeholders prior to submission and that proved to be our downfall in the end. The Maine Medical Association, the Maine Chapter of ACOG, the Nurse Practitioners Association, and even the Maine Chapter of the American College of Nurse Midwives did not support the bill, and particularly the MMA actively opposed it. The major concerns that arose were the non-mandatory nature of the bill, the lack of a “standardized” education for midwives, the reluctance to add another profession to the growing list of regulated professions, and the opposition to home birth in general.
The bill was amended in committee by the MMA which replaced the licensing bill with a bill that allowed for the purchase and administration of a small formulary of medications, but with no regulation of the midwives. This is the bill that ultimately prevailed due to a very strong MMA lobby, and we have been practicing under this law for the past 8 years. It was a strange and unprecedented law that gave unlicensed providers access to restricted medications with no way to enforce rules surrounding the acquisition or administration of these medications.
From 2008 until the submission of our successful licensing bill in 2014, much happened in the midwifery profession on the state, national and international level that set a very different stage for us in Maine. In 2010 the International Confederation of Midwives (ICM) issued Global Standards for Midwifery which challenged the 3 midwifery credentials in the U.S. (CPM, CNM, and CM) to begin an earnest dialog with the goal of strengthening midwifery in our country– USMERA was born. Alliances and agreements were made between leaders in the midwifery profession, including a move toward accredited educational pathways for CPMs. Ultimately, USMERA conversations with the national ACOG leadership resulted in the recognition of CPMs and a change in stance regarding CPM legislation if the USMERA agreements were included. At the same time, rising home birth rates in the U.S. caught the attention of the media and the medical organizations, quality evidence from around the world continued to show the safety of birth outside the hospital, and a workforce shortage for OB/GYNs was predicted in the near future.
This was the fertile soil we found as we moved towards submitting another bill in Maine. When the Maine CDC convened a Task Force to look at the safety of homebirth in Maine in 2011, the CPMs were invited to the table with the other maternity care players in the state to discuss ways to make homebirth more safe, relationships began to form and trust was built over the two years we met. It became apparent to many of us that licensing would be necessary to implement any structures of accountability, scope of practice boundaries, or a system of seamless collaboration among the spectrum of maternity care in the state. The task force was disbanded after a few significant accomplishments such as the development of Transport Guidelines from home to hospital and revisions of the birth certificate for better data collection.
In 2013 MACPM decided to write another bill to license CPMs for submission in 2014. Because of the national dialog and changes that were occurring at this time, the Maine Medical Association was given a $20,000 grant to support a facilitated collaborative bill-writing process in Maine. MACPM was tentative but ultimately agreed to a collaboration in hopes of avoiding the pitfalls of the 2008 experience. In January of 2015 the Homebirth Collaborative began meeting at the offices of the Maine Medical Association every two weeks, and with a neutral facilitator, began the bill-writing process. The stakeholders at the table included 5 CPMs, the Maine Medical Association, the Maine Chapter of ACOG, AHWONN, CNMs, and the Board of Nursing. Over the next year we wrote a bill that included many compromises on the part of the CPMs but also by the other stakeholders. The USMERA language regarding the requirement of an accredited education after 2020, or, for already certified CPMs, the NARM Bridge Certificate was included. The existing Complementary Healthcare Board was named as the regulatory body, as the CPMs had hoped, and a clause exempting midwives who are from and who serve distinct religious or ethnic communities was included. Other highlights of this bill include the authority to order lab tests and ultrasound, a clause to give other providers immunity in the case of consultation and transfer of care, and mandatory reporting requirements for data collection.
By far the most contentious point in the negotiations was around VBAC. It became clear that ACOG and the MMA, on the directive of their national leadership, would not budge on this issue. After spending many hours trying to find a middle ground, a less than optimal solution was found that would allow the process to move forward without the opposition of the medical lobby. The result was a prohibition on twins, breeches and VBAC until 2020 when this would sunset in the statute. Also, licensure for CPMs would not be mandatory until 2020, so those who want to continue to attend VBACs could wait to apply for their license until that time. Between enactment of the law and 2020, rules and regulations would be written in committee and jointly with the Maine Board of Medicine on twins, breeches and VBAC that would then replace this prohibition. We are confident that with the current evidence supporting VBAC, the precedent in many states, and with careful rules around its practice, we will maintain the ability to attend VBAC in this rule-writing process.
When the bill passed easily through both houses in early April, without any discussion on the floor, we were amazed. When it was vetoed by Gov. LePage (who vetoed 33 bills this session, mostly because he saw them as an expansion of government) we were prepared and continued to lobby the legislators to override the veto. When the veto was overridden easily in both houses we were ecstatic and I needed to pinch myself a few times to believe it was over. I was astounded by the bone-deep relief and excitement I felt in that moment– about the future possibilities that a unified and integrated midwifery profession could have on maternity care in Maine. I have always viewed licensure as a necessary threshold over which our profession must pass if we are to participate in a global movement and vision of a maternity care system that truly serves pregnant people and their families, offers a real choice of physiological birth, and has the potential to transform maternity care in the U.S. This is the visionary fuel that has kept me engaged in this effort in Maine for many years and today the future seems full of possibility in light of this political change in Maine.
We could not have accomplished this political feat without the amazing wisdom and leadership of our lobbyists from Moose Ridge Associates, Laura Harper and Betsy Sweet, and the incredible commitment to this bill by our lead sponsor, Senator Amy Volk (whom we discovered, quite by accident, had a home birth with her last baby). Thanks to all who helped in this effort from one very grateful CPM in Maine.
By: Heidi Fillmore, CPM, NHCM
The original article, “Overriding Vetoes: Maine’s Legislative Success Story,” was published in the Summer 2016 issue of Midwifery Matters.