du jour
GoodNews about midwifery
and the use of the Internet
March 8,
Legislative Recommendation on
Direct-entry Midwifery in Ohio
The following email and legislative report documents how the use of the Internet and the GoodNews Network web site enabled the midwives of Ohio to bring about favorable legislative recommendation.

It demonstrates the political power of the Web as a instantly available 24 hour library of statistical data and informational material able to be accessed by anyone, anywhere in their efforts to mold events to our advantage. The truth doesn’t have to be defended -- just revealed. The Web as a communication medium permits us to reveal the truth that has so long been invisible. I couldn’t be more pleased.

Date: Sun, 8 Mar 1998
From: Angela Cross

Subject: Final Legislative Report from the Direct Entry Midwifery Study Council -- Ohio


Dear Faith,

I have fowarded to you the results of the Direct Entry Study
Council of OH.I must share with you that much of the information that I gave
to the council was based on the info I gleaned from your web page. By the
will of G-d we were able to pre-empt everything the docs brought up in their
testimony: to the extent that the legislator in the chair on the night that
the obs gave their evidence recommended that she read the information that
WE gave her. Essentially she was saying they were ill informed and needed to
do some reading on the subject, and then she LENT it to her rather than ask
her for her uninformed opinion.

If you ever wonder if you are doing any good for midwifery, (I hope
you don't), let me tell you that without the information that you shared so
freely on your web page, I am certain that the Study Council report would
have been very different. There were days when I had a rebuttal for every
single thing the ob had to say.The legislative researchers would turn to me
after each comment and I was able to pull out a slew of studies, tables, or
a publication, or a book to give the facts, you name it, I had it; it was a
miracle. It became very obvious that the medical community did not have a
leg to stand on, and they fell back on the "The doctor says so, that's why"
tactic, which was just not good enough for these legislators any more.

With Many Thanks and Warmest Regards,   Angela Cross

Click here to go directly to the        
Recommendations for Direct-entry Midwifery - Ohio 
Position Paper on Direct entry midwifery by Anne Kinne, CPM


Subject: Final Legislative Report from the Direct Entry Midwifery Study Council

Note: This report will not be the full report (63 pages), but I will quote the
significant portions and summarize [in brackets] the rest. Abby J. Kinne, CPM


The General Assembly of The State of Ohio

January 16, 1998

Dear President Finan, Speaker Davidson, Minority Leaders and Members of the 122nd General Assembly:This constitutes the Final Report and Recommendations of the Direct Entry Midwifery Study Council created by Am. Sub. S.B. 154 of the 121st General Assembly.

The Council held eight meetings during the period from November 21, 1996, through November 12, 1997, and recieved oral and written testimony from representatives of the following groups: midwives, physicians, nurses, consumers, and other interested parties. The primary question examined at these meetings was whether Ohio should recognize direct-entry midwives and, if so, how they should be regulated.

The report includes the Council's recommendations to the General Assembly and a discussion of the history of midwifery regulation in Ohio and other states.

CHAPTER I -- Creation of the Direct-Entry Midwifery Study Council Section 13 of Am. Sub. S.B. 154 of the 121st General Assembly created the Direct Entry Midwifery Study Council consisting of eleven members:

(1) One certified nurse-midwife recommended by the Ohio Nurses Association; [Lowe]

(2) Two consumer advocates; [Celeste, Christensen]

(3) Two members of the House of Representatives and two members of the Senate, one from each political party in each chamber; [Kearns, Lawrence, McLin, Whalen]

(4) One direct entry midwife recommended by the Ohio Friends of Midwives; [Kinne]

(5) One member of the Ohio Board of Nursing; [Rosencrans]

(6) One member of the State Medical Board; [Egner]

(7) One obstetrician/gynecologist recommended by the Ohio State Medical Association. [Bryan]

S.B. 154 requires the Council to study the regulation of direct entry midives and submit a final report to the President of the Senate and the Speaker of the House of Representatives not later than December 31, 1997. The report must contain the Council's recommendations regarding whether Ohio should recognize and regulate direct entry midwives and what qualifications are needed for the recognition of direct entry midwives. On submission of the report, the Council ceases to exist.

When S.B. 154, which deals with licensure of advanced practice nurses, was introduced, it contained no references to direct entry midwifery. The Senate Health Committee added a provision prohibiting a person from engaging in the practice of lay midwifery, (1) including the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically unless the person holds a current, valid certificate of authority issued by the Board of Nursing to practice nursing as a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner. (2) However, this provision was removed in the House Health, Retirement and Aging Committee and replaced with the provision creating the Study Council. In sponsor testimony presented to that Committee on March 27, 1996, Senator Merle Grace Kearns gave the following explanation of the change:

*One change in the bill that I support at this time would be to eliminate the language concerning the prohibition on lay midwifery.

*At the request of the State Medical Board and the Board of Nursing, this language was added to the bill in the version which was adopted in September, 1995.

*However, hearing no opposition to this provision at that time, neither the subcommittee nor the Senate Health Committee discussed the issue in very much detail.

*Shortly after S.B. 154 passed the Senate, many calls were made to the House and Senate offices from consumers, objecting to "lay midwife language."

*Then, having recently met with the interested parties of this issue, it became clear that this particular subject needs closer scrutiny so that a comprehensive solution can be achieved.

*Therefore, an amendment has been drafted which would remove the language from the bill, while creating a task force to study the issue.

(1) Direct entry midwives are sometimes referred to as lay midwives. It appears that the terms are used interchangeably. Attached to this chapter is information prepared by the Midwives' Alliance of North America describing categories of professional midwives.\

(2) The performance of lay midwifery in accordance with the practice of religion was expempted from the prohibition

Recommendations of the Direct Entry Midwifery Study Council

The Direct Entry Midwifery Study Council met seven times during the period from November 21, 1996 through October 8, 1997 to receive testimony on the subject of direct entry midwifery from a variety of organizations, advocates, and consumers. With the exception of worker's compensation legislation, the meetings generated the greatest public response during the 122nd General Assembly with approximately 1,400 persons attending the meetings over the course of the year, including many persons who typically do not participate in the political process. In addition, Council members received approximately 300 pieces of correspondence and petitions concerning the issue of direct entry midwifery. A complete record of the testimony presented to the Council is available for review at the Legislative Service Commission, 77 South High Street, 9th Floor, Columbus, Ohio 43266-0342. On November 12, 1997, the Council met to discuss its recommendations to the General Assembly, which are set forth below. (3)

Majority Recommendation #1 -- Decriminalization

Council members Celeste, Christensen, Kearns, Kinne, Lawrence, Lowe, McLin and Whalen recommend that the practice of midwifery be legal in Ohio and that any ambiguity in the law on this issue be resolved to prevent prosecution of either direct entry midwives or parents who choose to use direct entry midwives.

Majority Recommendation #2 -- Registration

Council members Celeste, Christensen, Kearns, Kinne, Lawrence, Lowe, McLin and Whalen recommend that a voluntary registry be established that would permit direct entry midwives to register with either the Ohio Department of Health or a local board of health. A direct entry midwife certified by the North American Registry of Midwives (NARM) as a certified professional midwife (CPM) or by the American College of Nurse-Midwifes (ACNM) as a certified midwife (CM) could have the designations placed on the registry beside the midwife's name. The registry should be available to the public. Some Council members feel that it should be made clear that the registry is not a "stamp of approval" of direct entry midwifery by the state; however, Council member Kinne believes that midwives certified by NARM as CPMs should be given state recognition.

(3) Attached to this report as the Appendix are legislative issues raised by the majority and minority recommendations. These are issues that would have to be resolved if legislation is drafted to implement the recommendations.

Majority Recommendation #3 -- Informed Consent

Council members Celeste, Christensen, Kearns, Kinne, Lawrence, Lowe, McLin and Whalen recommend that direct entry midwifery be coupled with some type of informed consent, both to ensure that parents who choose that alternative are educated and to protect the direct entry midwife by providing evidence that parents who choose to use a direct entry midwive's services have made an informed choice. The informed consent form should describe the midwife's experience. Some council members believe that the use of informed consent should be required of midwives listed in the registry described in Majority

Recommendation #2, but no consensus was reached on this issue.

Majority Recommendation #4 -- Public Information

Council members Celeste, Christensen, Kearns, Kinne, Lawrence, Lowe, McLin and Whalen recommend that the Ohio Department of Health be required to prepare a brochure regarding the options available to parents in choosing someone to assist them in the delivery of their baby. The brochure should contain an objective explanation of the differences among the following types of practitioners: physicians (OB/GYN and family practice), certified nurse-midwives, certified professional midwives, certified midwives, and direct entry midwives.

Minority Recommendation #1 -- Licensure

Council members Bryan, Egner and Rosencrans recommend that direct entry midwifery be prohibited unless the midwife can demonstrate competencies, educational preparation, and training equivalent to a certified nurse-midwife. Currently, the ACNM offers the only process that assures that non-nurses meet those criteria.

Minority Recommendation #2 -- Existing Barriers to Home Birth

Council members Egner, Kearns, Lawrence, and Rosencrans feel that the availability of home birth as an option for parents could be expanded by eliminating malpractice and liability barriers facing physicians and certified nurse-midwives who attend home births by requiring insurance coverage or providing immunity from liability for malpractice.

Minority Recommendation #3 -- Statistics

Council members Egner and Rosencrans recommend that, if direct entry midwifery is not regulated, direct entry midwives be required to report statistics regarding their practice.

CHAPTER III -- Individual Position Statements of Council Members [Below is my (Kinne) position paper...I do not yet have other statements which were included in the final report.]

Position Paper on Direct-Entry Midwifery
Abby J. Kinne, CPM Direct-Entry Midwife

Direct-entry midwives practicing the prevention-oriented, woman-centered midwifery model of care in and out of the hospital provide a very effective kind of care desired by many women--a model of care that is appropriate for a majority of pregnant women and that has been proven to reduce the incidence of birth injury, trauma and cesarean section.

It has been estimated that by developing midwifery care, demedicalizing childbirth, and encouraging breastfeeding from $13 billion to $20 billion a year could be saved in health care costs. Below are the main points which were demonstrated in testimony during our year-long study of direct-entry midwifery:


As stated in the Majority Report, any ambiguity in the law regarding the practice of direct-entry midwifery should be resolved to prevent prosecution of either direct-entry midwives or parents who choose to use direct-entry midwives. Although the Majority Report uses the term "decriminalization," current Ohio law does not clearly prohibit the practice of direct-entry midwifery. However, given the very strong public support for direct-entry midwifery expressed during the Direct-Entry Midwifery Study Council hearings, applicable law should be amended to state clearly that the practice of direct- entry midwifery is lawful in this State.


Impressive participation on the part of the public demonstrated the desire and importance of preserving their right to deliver their baby where and with whom they choose. It became clear that women and families will continue to have out-of-hospital births. Furthermore, attempts to force women and families to have their births in hospitals not only will be unsuccessful, but also reflects poor public policy and a limiting of health care choices.


All statistical studies examined by the Study Council demonstrated, without exception, that out-of-hospital births attended by direct-entry midwives, both in Ohio and worldwide, were as safe as, or safer than, comparable in-hospital births.


An independent evaluation by Ohio State University demonstrated that the competency-based national certification process for direct-entry midwives developed by the North American Registry of Midwives (NARM) was both legally defensible and psychometrically sound assuring public safety and competent practice by direct-entry midwives.


The overwhelming testimony of the public demonstrated that the nature of care desired by the public could not be provided by either physicians, nurses or certified nurse-midwives who are neither trained nor inclined to attend out- of-hospital births. Eliminating malpractice liability barriers to attendance at out-of-hospital births would not ensure adequate numbers of competent practitioners to serve the public. These same practitioners are both unwilling and untrained to attend out-of-hospital births.


Testimony demonstrated that direct-entry midwives must be legally permitted, under the law to perform certain emergency procedures (such as episiotomies, suturing and newborn resuscitation) and to administer certain medications (such as oxygen and treatments for postpartum bleeding) in order to be prepared to respond to unanticipated emergencies when they occur.


Public testimony revealed that a significant portion of the state's population choosing out-of-hospital birth are either uninsured or underinsured. Out-of- hospital birth is a cost-effective solution for these families which does not compete with current practitioners. In this era of escalating health care costs, midwives are the one health care practitioner that can significantly impact the bottom line positively without compromising the health or safety of the client.


Midwives and the families they serve, including where midwives are used as a result of religious or cultural practice, should have access to physicians and hospitals, without prejudice, in the event that complications arise.

CHAPTER IV -- Midwifery Regulation in Ohio

Current Law

Although the Revised Code includes provisions governing the practice of nurse-midwifery, it does not experessly prohibit the practice of midwifery by persons who are not nurses. As a result, the legal status of midwifery services performed by persons who are not nurses remains unclear until the Revised Code is interpreted by a court or amended. In a proceeding challenging the practice of midwifery by non-nurses, a court could reach any of thefollowing conclusions:

1. The practice of midwifery by a non-nurse is prohibited because it is the practice of   nurse-midwifery without a certificate.

2. The practice of midwifery by a non-nurse is prohibited because it is the  unauthorized practice of medicine.

3. The practice of midwifery by a non-nurse is not regulated.

The report then describes Ohio law regarding the "Practice of nursing" and the "Practice of medicine." It then describes the Legislative history which applies to the practice of midwifery in Ohio.]

CHAPTER V -- Direct Entry Midwifery Regulation in Selected States

This chapter summarizes the regulation by selected other states of the practice of direct entry midwivery. Of the 17 states (9) discussed in this chapter, eleven regulated the practice of midwifery by direct entry midwives, four authorize direct entry midwifery practice by judicial interpretation, and two have little or no law that deals with this issue.

(9) The following states are discussed: Alabama, Arkansas, Florida, Georgia, Idaho, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, New Jersey, New York, Oregon, Tennessee, Texas, Vermont, and Washington. [Appended to this chapter were figures illustrating "Legal Status of Direct-Entry Midwifery in the United States, April 1995" from Sue A. Blevins, The Medical Monopoly Protecting Consumers or Limiting Competition? (Washington: Cato Institute, 1995), p. 15 and "Legal Status of Direct Entry Midwives: State by State Analysis" (as of 9/22/97) from the MANA Web Page.]


Comparison of Requirements for Midwife Certification by the North American Registry of Midwives (NARM)  and the American College of Nurse-Midwives (ACNM)

This chapter consists of a brief synopsis of the requirements for midwife certification by the North American Registry of Midwives (NARM) and the American College of Nurse-Midwifes (ACNM) and is followed by information prepared by those organizations concerning their certification processes


For entry-level midwives, NARM requires a person to meet certain experience requirements, pass a written exam, and successfully complete a skills assessment. The experience requirements include (1) attending a minimum of twenty births as an active participant; (2) functioning as a primary midwife under supervision at (a) an additional twenty births, ten of which must be in a home or other non-hospital setting and at least three of which must be with women for whom the applicant has provided primary care during at least four prenatal visits, birth, a newborn exam, and a postpartum exam, (b) seventy- five prenatal exams, including twenty initial exams, (c) twenty newborn exams, and (d) forty postpartum exams. After meeting the experience requirements, the applicant is scheduled to take the written examination. The written examination is designed to test the knowledge and skills necessary for competent midwifery practice and is based on a survey of practicing midwives.

After passing the written examination, the applicant must pass a hands-on skills assessment administered by a trained evaluator. For the skills assessment, each applicant is given a study guide outlining the skills, knowledge, and abilities essential for midwifery. The applicant's preceptor or supervisor must attest that the applicant is proficient in each area listed in the study guide. NARM-certified midwives are required to obtain CPR certification and develop and use practice guidelines and an informed consent document, as well as submit three letters of reference and documentation of certain experience, knowledge, and skills.


An applicant who is not a nurse can obtain certification through ACNM by: (1) graduating from an ACNM-accredited program in midwifery, (2) obtaining certification from the program director that the applicant is safe to practice midwifery, and (3) passing an examination developed and administered by ACNM.

Currently, the only ACNM-accredited midwifery program is a post-baccalaureate program at the State University of New York.

[Attached to this chapter is a copy of "How to Become a Certified Professional Midwife" published by the North American Registry of Midwives (NARM)] and "Information for Candidates of the National Certification Examination in Nurse-Midwifery and Midwifery" published by the American College of Nurse- Midwives (ACNM).]

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