Midwife Partners in Women's Wellness

When we lost our written collaboration agreement to deliver at Shawnee Mission Medical Center, 25 women suddenly had nowhere to deliver their babies and lost the provider of their choice, because we essentially lost our licenses to practice our profession. The profession of Nurse-Midwifery.  The profession that we are educated in, that we are licensed in, and that we have many years of experience in.  The profession that cares for low risk pregnant women all over the world. The profession that supports and believes in birth as a normal, physiological life event.  A life event that typically needs no medical intervention.

Needless to say these women were pretty shocked and confused, and we had no answer for them. We have never been told why, and we will likely never be told why. Our ability to practice nurse-midwifery should only depend on whether we are educated, competent, and licensed, which not surprisingly is the job of the Board of Nursing, and not the job of individual doctors. We have Constitutional rights that guarantee us due process. This was denied us, and we effectively lost our licenses. 

The heart of the issue in this case is the requirement of a WRITTEN collaboration agreement. As trained, educated, and experienced nurse-midwives, we know when to consult, when to collaborate. We oftentimes refer and consult with physicians and physician specialists. The requirement of a written collaboration agreement serves no other purpose than to stifle an otherwise legal profession. It effectively delegates the licensing power of the Board of Nursing to the capriciousness of individual physicians who can refuse to sign one. We do not get to practice our profession unless we find a physician who “likes” us and midwifery, and who has supportive partners and hospitals. Even then, some may see us as competition or believe the agreement puts them at risk of liability for our decisions. Furthermore, written agreements do not protect patients in any way. In 25 states, CNMs practice independently, without the requirement of a written collaboration agreement, and in 7 more they practice independently but are required to have a collaboration agreement only in order to prescribe medications. There has been no public health crisis because of the independent practice of nurse-midwives in any of these states. 

A recent response from the Executive Vice President and CEO of ACOG, after informing him of the lack of collaboration opportunity in our area, affirmed that “(he was) aware that collaboration at the national level does not always translate to the local level” and that “the collaboration between CNMs and OBGYNs varies regionally.” From the Executive Vice President and CEO himself, our ability to practice our profession “varies regionally”, depending on whether there is a physician “willing” to sign a collaboration agreement, depending on our luck of the draw. 

While the loss of collaboration was stressful for our patients, it was just as rough for us. Not only because we felt awful for them, but because for 3 years we had been building a successful business, and then, there we were, back to square one for no reason. We were not unsafe.  We were successful. We were well-liked by our patients and their families. We had less than a 10% c/s rate, an 87% successful VBAC rate, an epidural rate of 15%, and a maternal/infant infection rate of 0%. With maternity care in this country garnering much attention to its failures at present, these statistics are enviable.   

True midwifery care is based in education, informed consent, support, patience, and a belief in women.  A written collaboration agreement does not change our philosophy, nor does it provide some sort of safety net.  We only ask that we, and our clients, are protected from arbitrary decisions that interfere with our clients’ care and our ability to practice our chosen legal profession.  The majority of the states in this country have eliminated the requirement of a written collaboration agreement without any negative consequences, and it will work just as well in Kansas. We ask to be able to do what we love, which is providing the best care possible to women, babies and families. 

Julie Gorenc, CNM, CPM

Kara Winkler, CNM