Legislature Looking to Give Midwives Drug Availability to Help With Patient Safety

Elizabeth Maixner had her first baby when she was 15 in a hospital. She worked with a midwife in the hospital and said especially at such a young age, she appreciated the personal support the midwife added to the experience, which gave her, and her mom, comfort during an unknown process.

"She not only supported me in my pregnancy, but she also supported my mother, which was huge," Maixner said.

Maixner is now a mother of three and was 30 and 33 when she had her second and third children. When it was time to decide where to have her next babies, she said she wanted that personal relationship a midwife offers. She elected at-home births for her next two deliveries.

"It was just such a wonderful experience to be in my own environment, in my own things, you know, all the comforts of home," Maixner said. "Having a child is very emotional. It's very personal. It's very vulnerable. And to be in your own space, in your own bed with, you know, dogs and whatever else is in the house is wonderful."

Montana has the fifth highest percentage of home births in the nation, according to statistics gathered by the Pew Research Center. And, for the most part, those births are attended by what are called “direct-entry” midwives, or certified professional midwives.

A bill gaining support in the Montana Legislature would expand the permissions of those midwives, allowing them to obtain, carry and administer certain medications that supporters say could be life-saving for both mothers and newborns.

House Bill 392, sponsored by Rep. Jodee Etchart, R-Billings, would add medications like local anesthetics and postpartum anti-hemorrhaging agents to the list of drugs midwives could obtain and administer. The bill would not provide direct-entry midwives any powers to prescribe patients medications.

It is one of several bills in the 2023 legislature that aim to increase health care access by expanding certain provider roles in the state. Etchart is also sponsoring House Bill 313, which would allow physician assistants to practice without a supervision agreement from a doctor. Sen. Tom McGillvray, R-Yellowstone County is sponsoring Senate Bill 112, which would expand the limited authority pharmacists have to prescribe medications in the state.

“This bill will enhance patient safety, reduce costs for the patient and insurer, improve efficiency and access to maternity and care and expand consumer choice,” said Amanda Osborne, a practicing midwife and owner of the Helena Birth Studio.

Currently, 33 states and the District of Columbia allow direct-entry midwives to carry prescription drugs and tools to aid in the birthing process.

Osborne said the Legislature hasn't touched the laws that govern what medications direct-entry can use for more than 30 years and that with the evolution of medical practices and the training midwives do, it's time to update the laws.

"All of those things are necessary to enhance safety. So that's the care that women deserve to have or no matter where they're choosing to give birth, whether we agree with that or not,” Osborne said. “You still deserve that advanced safety.”

Thirty-eight direct-entry midwives are currently serving across the state in at-home births or at birthing centers. They hold certified professional midwives or CPM certifications that must be renewed every three years to continue practicing.

There are two recognized types of midwives in the state: A certified nurse midwife, who has undergone training to be a registered nurse and specializes in women's reproductive health and childbirth and a direct-entry midwife who did not attend nursing school but has certification in the area.

Under current law, direct-entry midwives have to work with other providers, like a certified nurse midwife, to get their patients access to these labor and delivery medications. Osborne said this system is not advantageous to the safety of patients and questioned how midwives are supposed to obtain life-saving medication in a timely fashion during a birth.

Osborne was one of 13 supporters who testified for the bill at a House Human Services Committee hearing on Feb. 10. Supporters included mothers, midwives and a pharmacist who testified on the safety and necessity of the drugs allowed in the bill.

"I have reviewed the medication list for direct-entry midwives and all of these medications are completely appropriate for administration and utility," Stephanie Wuerffel, an emergency department pharmacist in Montana, said. "I think these are very routine medications, including the medication for postpartum hemorrhage."

Supporters of the bill also mentioned a drug shortage in the country that has made it extremely difficult for midwives to obtain the proper medications because they cannot obtain them directly.

HB 392 had two "soft" opponents, including Jean Branscum, CEO of the Montana Medical Association.

Branscum said her group opposes the bill only because of its wording and suggested an amendment to include stronger language that would strengthen the new law and add an item to the list of usable drugs for direct-entry midwives.

The additional medication added in the amendment is Terbutaline, used to stop or slow contractions to help with preterm labor.

Osborne said Washington is the only other state that offers this medication to direct-entry midwives. She said it would be rare that a midwife would need to use this medication because preterm labor is a high-risk condition and direct-entry midwives are required to transfer high-risk patients to a doctor.

"If we are faced with that scenario, we are required by the rules to transfer it to a physician in a hospital appropriately. So we wouldn't want to give the impression that we would ever use that," Osborne said.

But, in cases in which a baby is full-term, but an emergency transfer is necessary, the medication could be crucial, especially in rural areas.

"This is particularly true for midwives who practice in rural areas far away from a hospital in the case of a prolapsed cord where the umbilical cord is coming out. It could stop contractions or at least slow them enough to take the pressure off the cord as you’re transporting to the hospital for surgery,” Osborne said.

Osborne told the committee that because women are already increasingly choosing at-home or birth-center births attended by midwives, the bill is not about bolstering the practice, but about the safety of patients.

“We’re not in this for us,” Osborne said. “It’s not going to get me more business. It’s going to make it safer for them.”

Caven Wade is a student reporter with the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Broadcasters Association, the Montana Newspaper Association and the Greater Montana Foundation. He can be reached at [email protected].