A midwife is a professional with specialized training and experience in pregnancy, childbirth, and postpartum women's health. Midwives offer comfort and professional experience to pregnant women and their families during pregnancy. However, when a midwife does something wrong during pregnancy, the mother or infant may suffer injury or death.
Midwifery Practice in Maryland
Midwife requirements and certifications vary by state. In Maryland, both nurse midwives and direct entry midwives can be licensed and practice as midwives. Certified Professional Midwives (CPMs) are licensed in Maryland as Licensed Direct Entry Midwives (LDEMs). Certified Nurse Midwives in Maryland are licensed as advanced practice registered nurses with the Maryland Board of Nursing.
Midwife Training and Certification
Training and certification for midwives depend on whether the midwife is a certified nurse midwife or a direct entry midwife. Certified nurse midwives generally have more training and are regulated by state nursing boards. Direct entry midwives do not require training as a nurse and generally have more restrictions on their scope of practice.
Direct entry midwives generally require certification as a Certified Professional Midwife (CPM) by the North American Registry of Midwives (NARM). NARM developed the national CPM credential, with standardized training, knowledge, skills, and experience. To be a CPM requires completion of an accredited education program, out-of-hospital birth experience, and passing a written exam and hands-on skills evaluation. The CPM is not required to be a nurse.
The Certified Nurse Midwife (CNM) is an advanced nursing credential. This requires education in both nursing and as a midwife, generally in a hospital setting. CNMs are advanced practice nurses. This generally requires a minimum education level of a bachelor's degree, in addition to a qualifying nurse-midwifery program and passing the required exam.
Direct Entry Midwife
A licensed direct-entry midwife must be licensed by the Maryland Board of Health. In order to qualify for initial licensure as a direct-entry midwifery in Maryland, an applicant shall:
- Be of good moral character;
- Be a high school graduate or have completed equivalent education;
- Be 21 years old or older;
- Hold a current cardiopulmonary resuscitation (CPR) certification issued by the American Red Cross or the American Heart Association;
- Have completed in the past 2 years the American Academy of Pediatrics or American Heart Association Neonatal Resuscitation Program (NRP);
- Hold a current valid Certified Professional Midwife credential granted by NARM; and
- Have completed a qualifying midwifery education program.
A qualifying midwifery education program shall be accredited by MEAC or ACME. Alternatively, if the applicant was certified by NARM as a certified professional midwife on or before January 15, 2017, through a non-MEAC accredited program, but otherwise qualifies for licensure, the applicant must provide:
- Verification of completion of NARM-approved clinical requirements; and
- Evidence of completion, in the past 2 years, of an additional 50 hours of continuing education units approved by the Board and accredited by MEAC, the American College of Nurse Midwives, or the Accrediting Council for Continuing Medical Education, which included:
- 14 hours of obstetric emergency skills training such as a Birth Emergency Skills Training (BEST) or an Advanced Life Saving in Obstetrics (ALSO) course; and
- 36 hours of pharmacology, lab interpretation of pregnancy, antepartum complications, intrapartum complications, postpartum complications, and neonatal care courses.
Direct Entry Midwifery Scope of Practice
Under Maryland law, direct entry midwives have a more limited scope of practice compared to certified nurse midwives. Direct-entry midwifery practice includes:
- Providing the necessary supervision, care, and advice to a patient during a low-risk pregnancy, labor, delivery, and postpartum period;
- Authorized newborn care in a manner that is consistent with national direct-entry midwifery standards and based on the acquisition of clinical skills necessary for care;
- Obtaining informed consent to provide services to the patient;
- Discussing general and specific risk factors associated with the services to be provided;
- Discussing conditions that the licensed direct-entry midwife cannot provide;
- Discussing conditions under which consultation, transfer of care, or transport of the patient must be implemented;
- Obtaining a health history of the patient, including a travel history, and performing a physical examination;
- Developing a written plan of care specific to the patient, to ensure continuity of care throughout the antepartum, intrapartum, and postpartum periods;
- Evaluating the results of patient care; and
- Consulting and collaborating with a health care practitioner regarding the care of a patient, and referring and transferring care to a health care provider.
A licensed direct-entry midwife must consult with a health care practitioner regarding the care of a patient. They must also document the consultation, consultation recommendations, and may be required to discuss the consultation with the client in certain circumstances.
A direct entry midwife is prohibited from certain actions that a certified nurse midwife is able to perform. A licensed direct-entry midwife must also arrange for immediate emergency transfer to a hospital if the patient requests a transfer or specific conditions occur. Direct-entry midwives have a prohibition on:
- Pharmacological induction or augmentation of labor or artificial rupture of membranes before the onset of labor;
- Surgical delivery or any surgery except an emergency episiotomy;
- Use of forceps or vacuum extractor;
- Administration of an anesthetic, except for the administration of a local anesthetic;
- Administration of any kind of narcotic analgesic; or
- Administration of any unauthorized prescription medication.
In addition to the prohibitions, a direct-entry midwife may not assume care or continue to take responsibility for a patient's pregnancy and birth care if certain disorders or situations are found to be present, and these include:
- Diabetes mellitus, including uncontrolled gestational diabetes;
- Hyperthyroidism treated with medication;
- Uncontrolled hypothyroidism;
- Epilepsy with seizures or antiepileptic drug use during the previous 12 months;
- Coagulation disorders;
- Chronic pulmonary disease;
- Hypertension, including pregnancy-induced hypertension;
- Renal disease;
- Previous uterine surgery, including a cesarean section or myomectomy;
- Premature labor (gestation less than 37 weeks);
- Placenta previa or abruption;
- Preeclampsia; and
- Other common and uncommon diseases, conditions, or disorders.
Certified Nurse Midwife
A registered nurse may practice as a nurse-midwife graduate for a limited time before certification if they meet certain requirements. This includes:
- Qualification to sit for the AMCB national certifying exam or other approved certifying exam;
- Practice is under the supervision of a certified nurse midwife;
- The supervising certified nurse midwife signs a written supervision agreement on the required form to provide the supervision; and
- The nurse midwife graduate files with the Board a copy of the admission slip to the Board-approved certifying examination and a copy of the signed supervision agreement.
In Maryland, a nurse-midwife must have (1) license to practice registered nursing in Maryland; and (2) certification as a nurse-midwife from the AMCB or any other certifying body recognized by the Board, and then must conduct the following to be certified by the state:
- Complete the application for certification as a nurse midwife;
- Submit an affidavit that the applicant agrees to comply at all times with the clinical practice guidelines in accordance with Regulation .01B(7) of this chapter when providing clinical midwifery services; and
- Pay all fees.
If the applicant's nurse-midwifery program was completed before July 1, 2014, and was not at a Master's degree or higher level, but the applicant otherwise qualifies, the applicant for certification as a CNM shall provide the Board with:
- Verification of completion of a nurse-midwifery program recognized by AMCB; and
- Current national certification by AMCB.
Certified Nurse Midwife Scope of Practice
Under Maryland law, a certified nurse midwife has a limited scope of practice. A certified nurse midwife may perform the following functions:
- Independent management of clients appropriate to the skill and educational preparation of the certified nurse midwife and the nurse midwife's clinical practice guidelines;
- Consultation or collaboration with a physician or other health care provider as needed; and
- Client referrals with complications beyond the scope of practice of the certified nurse midwife to a licensed physician.
In addition, a certified nurse midwife has the right and obligation to refuse to perform any delegated medical act, oral or written, if, in the certified nurse midwife's judgment, it is unsafe or an invalidly prescribed medical act or beyond the competence of the certified nurse midwife, in which case the nurse-midwife shall notify the delegating physician at once.
A certified nurse midwife is required to keep a record of all cases attended. This includes maintaining a medical record for each client, and in the case of a transfer of care to another facility, transfer the client's medical records with the client. The certified nurse midwife shall also have available written clinical practice guidelines that cover all aspects of care and practice. This includes a plan for emergency consultation, plan for a transfer of care, and plan for admission to a nearby hospital.
Midwife vs. Doula
Some people mistake a midwife for a doula. It is important to understand that a midwife is not the same a doula or birth companion. A certified midwife requires formal education, training, licensing, and certification. This includes pregnancy and birth-specific training and education in an accredited program. However, doulas are not regulated by state or federal law. There is no licensing agency for doulas and no formal requirements to carry the title of a doula. An individual with no formal training, education, or experience could call themselves a doula.
Midwife Malpractice in Maryland
Pregnancy and birth are natural events in life. However, there may also be a significant level of risk associated with pregnancy. When something goes wrong during pregnancy, the pregnant woman and infant child may suffer a serious injury or die. This is one reason why the insurance costs for obstetricians/gynecologists (ob/gyns) are so high. Ob/gyns have some of the highest rates of being sued by patients.
Like ob/gyns, nurses and midwives can also be responsible for causing injury to a baby or the mother during birth. Midwives owe their patients a duty of care. If a midwife fails to act within their standard of care and the patient is injured as a result, the midwife may be liable for any damages caused. This is also known as malpractice or professional negligence.
A midwife may be considered professionally negligent if they fail to use the level of skill, knowledge, and care in treating their patients as other reasonable midwives would use in the same or similar circumstances. The standard of care is generally demonstrated by expert testimony from other midwives who use their experience to give their opinion as to whether the midwife met the standard of care or breached the standard of care.
A jury determines, based on the evidence and testimony, whether the midwife breached the standard of care. The jury then determines whether the breach of the duty of care caused injury to the patient that resulted in some harm. If the breach of care caused the injury, then the jury will determine what damages the patient should receive to compensate them for their injury.
Common Complications Involving a Midwife
There are a number of complications during pregnancy or birth that can lead to an injury for the mother and/or baby. This includes problems with the pregnancy before birth, during birth, or during postpartum. Complications involving midwife care during birth can include:
- Anemia in the mother or child
- Breech birth
- Slow labor
- Multiple births
- Posterior position
- Amniotic Fluid Embolism
- Placenta Previa
- Placenta Accreta
- Uterine Rupture
- Gestational Diabetes
- Nuchal Cord (where the umbilical cord is wrapped around the baby's head)
- Cephalopelvic Disproportion (where the baby's head will not fit through the mother's pubic bone)
- Excessive bleeding after childbirth.
When a certified direct-entry midwife is handling a birth at home, they are required to transfer care when something goes wrong, or if the patient requests a transfer of care. When complications occur during pregnancy, the baby may suffer birth injuries, including:
- Perinatal asphyxia from oxygen deprivation
- Swelling of the baby's scalp
- Erb's Palsy
- Bone fractures
- Cerebral Palsy
- Spinal cord injuries
- Facial paralysis
- Subconjunctival hemorrhage
Midwife Accident Injuries and Damages
When a midwife fails to perform their duties as required by their scope of practice and standard of care, they may be liable for injuries and damages to the mother or baby. Examples of failure of the midwife's duty of care to the mother and child may include:
- Failure to inform the patient of limitations on the midwife's scope of practice;
- Failure to identify problems in the pregnancy;
- Failure to transfer care when a problem occurs;
- Failure to transfer care when the patient requests a transfer of care;
- Poor record-keeping and documentation;
- Unauthorized administration of drugs;
- Poor infection control;
- Providing care without assistance;
- Failure to monitor the mother's vital signs;
- Failure to monitor the baby's vital signs; or
- Improper use of assisted delivery tools (e.g., forceps).
In a midwife malpractice case, if the midwife is found responsible for causing the mother or baby's injury, the family may be able to receive an award for damages. Damages may include compensatory damages for money spent on treatment, costs of additional medical treatment, hospital care, the cost of continued care, lost wages, pain and suffering, and loss of enjoyment of life.
Many birth injuries leave the family facing expensive medical care for the rest of their child's life. Care for a mentally or physically-impaired child can cost millions of dollars over the course of the child's natural life. In the case of malpractice, the parties responsible for causing the injury should be held accountable for the damage caused.
Midwife Malpractice and the Death of a Child
The most tragic possibility when a midwife makes a mistake during pregnancy involves the death of the child. Death of a child during pregnancy, birth, or shortly after birth can leave a family devastated. While there is no amount of money that can replace the loss of a child, a wrongful death claim may allow the family to seek compensation.
The damages available in a wrongful death case can help the family pay the costs of funeral expenses and compensate them for their loss of support. A wrongful death claim can also help to make sure the person responsible is held accountable for their negligent actions.
Midwife Malpractice Lawyers Gilman & Bedigian
If you were injured because of an accident or mistake involving a midwife's care, you may have a legal claim to seek compensation in court. When filing a malpractice case against the midwife, the injured patient can seek damages for lost wages, pain and suffering, medical bills, and other compensation. Family members may also be able to seek compensation. You should not have to suffer because of your midwife's negligence.
At Gilman & Bedigian, we will use our experience, knowledge, and dedication to fight for you to receive the compensation you and your family deserve. Our aggressive trial lawyers have helped our clients recover millions of dollars in compensation related to birth injuries and other medical malpractice. Contact us online or call our law office at (800) 529-6162 for a free consultation.