Licensing, credentialling, and quality of care - Oregon USA

This is not the carefully crafted piece I am still working on, but rather is a few random comments. I have a good friend in Portland Oregon who has been a midwife for more than 20 years. She has been published in Midwifery Today, she organizes continuing education workshops for midwives, she is truly knowledgeable and skilled in her profession. And she is not licensed. She practices perfectly legally in her state. There was a court decision several years ago in Oregon that stated the practice of midwifery is not the practice of medicine, as long as the midwife does not use interventions that are considered medical (such as drugs including pitocin, surgery, forceps or vacuum, etc.). Herbs, physical interventions using the hands, etc. are not considered medical, nor is cutting the cord. There are no standards that exclude any kind of patient from the midwife's practice, other than personal choice on the part of the midwife and patient. Therefore, an unlicensed midwife can agree to attend breeches, VBACs, multiple gestations, or whatever - and can charge for services rendered. Most have transfer agreements with at least one doctor or hospital if needed. But no 3rd party payers (insurance, Oregon Health Plan) will reimburse for this care. Care with these midwives is strictly caveat emptor. Most are highly qualified, and are more than willing to provide references, educational background, and a written informed consent agreement to patients, but not all.
There are also licensed midwives in Oregon.
Certified Nurse-Midwives are licensed as nurse-practitioners, and must have a master's degree. Their scope of practice is determined through the Board of Nursing. The fee for this license is a few hundred dollars, not including costs for mandatory continuing education. CNMs practice can be at home, in birth centers, or in hospitals. Most CNMs have pretty strict boundaries on whom they will attend, and stratify patients in to one of three levels of care - 1) midwifery only, 2) midwifery with physician consult or 3) refer all care to physician. Most CNMs do not attend breeches or multiple gestations routinely.
Licensed Midwives must go through a credentialling process including verification of experience and a written exam. With licensing, the midwife is allowed to carry and use certain medications and controlled substances (pitocin, methergine, oxygen) under protocols. The licensing agreement also excludes certain classifications of pregnancy from care by this group. (I don't remember the exact boundaries, but they are the kinds of moms that a CNM would also consult on or refer out). The licensed midwife will also have working relationships with physicians for conslutation and referral. In Oregon, licensed midwives were able to bill insurance and the Oregon Health Plan until the move into HMOs. Licensing fees for this class of midwife is in the thousand dollar range, as the Board is required by state law to be self sufficient.
Anyhow, my friend was on the Board for licensing of midwives, and was licensed among the first group after establishment of the law, but has let her licensure lapse. And she isn't the only one. Licensure was held out to them as a potential for being able to practice midwifery with a firmer foundation. Legal recognition, 3rd party reimbursement, legal access to life saving anti-hemorrhagic drugs, more articulated transfer of care for the small percentage of moms who need it - these all seemed to be pretty clear advantages. But the reality has been different. There was an increase in overhead cost, a loss of autonomy, and the 3rd party reimbursement never really happened as promised. And so my friend, and many like her, are back to where they were before licensure came in. For hemorrhage, she uses massage, compression and herbs, and transports if needed. Although she has the skills to start an IV, and the knowledge of how to use anti-hemorrhage drugs, the costs of the license to use them are too high, both to her and to the families she serves.