Last week the Kentucky state legislature passed Senate Bill 110 which will allow optometrists to perform some basic laser surgery procedures that have generally been limited to opthalmologists. The bill is aimed at improving the possibilities of eye care in rural Kentucky where residents might have to travel far distances to see opthalmologists in larger cities for surgery. However, many opposed the bill which passed through Congress with some speed.
“I think this is bad medicine for Kentucky and for the people of Kentucky,” said Dr. Tim Conrad, an ophthalmologist. He, like many other opponents, says optometrists aren’t qualified to perform eye surgeries. Unlike ophthalmologists, optometrists do not go to medical school, instead they go through a four year training program.
-WHAS11’s Brooke Katz reporting
The backers of the bill say…
it allows optometrists to perform only procedures they’re trained for, none of which would require general anesthesia. It would also specifically exclude certain complex procedures like Lasik surgery. -WHAS11
It is no secret that healthcare in general and quality healthcare in particular can be hard to find in the rural communities of Kentucky. In southeastern Kentucky, where I am based there are many counties without hospitals at all and very few family practice doctors for general medical care. When looking at this issue from the eyes of an expecting mother, we can begin to see the hardship they are expected to bear just when attempting to seek regular maternity care.
The situation is even worse in neighboring Kentucky, where 25 percent of the state’s obstetricians have moved away or stopped practicing since 2001, leaving 71 out of 120 counties without one. Every year, at least 3,000 pregnant women in the state scramble to find new doctors or midwives. Last year, Rashelle Perryman had her third child at a hospital 45 miles away from her home. Ironically, she’d been the obstetrics-ward nurse supervisor at Crittenden County Hospital, in Marion, Kentucky, until the ward closed in 2005. “There are doctors here who want to deliver babies, but they can’t afford to,” says Perryman. “The sad part is that pregnant women are the ones left bearing the burden.” – Jeannette Moninger (Parents Magazine)
71 out of 120 Kentucky counties left with no maternity care provider. The demands this makes on pregnant women and their families to seek out and keep up with their maternity care for some can be insurmountable.
When I consider this, I think about how things used to be when the midwifery model of care was prevalent in the mountains of eastern Kentucky. There was a time when our maternal and infant mortality rates in our area were dismal, but pioneers of nurse midwifery such as Mary Breckinridge came to the area in service. Not only did they improve outcomes, but they had better outcomes than those of hospital physicians of the day. The nurse midwives of that time attended births in homes, medical clinics, and occasionally in the area hospital. The vast majority of births in our region occurred outside of the hospital during that time.
However, as access to hospital care became a bit more prevalent in the mountain region, the numbers of both lay and nurse midwives began to dwindle. With this transition childbirth had to move out of the home and into the hospital where births were attended by the few obstetricians and midwives that practice through those hospital facilities. Currently, many of our maternity care providers are overworked, and facing financial burdens of high malpractice insurance costs and poor reimbursements from Medicaid and insurance providers.
It’s this burden that keeps David Doty, DO, chair of ACOG’s Kentucky chapter and an ob-gyn in Maysville, in the delivery room. “My partners and I are the only obstetricians within a 60-mile radius. I can’t, in good conscience, leave these women without medical care,” says Dr. Doty, who at age 56, admits that he’d like to stop doing deliveries. Unfortunately, finding candidates to fill his shoes is becoming increasingly difficult. -Jeannette Moninger (Parents Magazine)
With this added burden of large patient numbers, and little incentive in the practice of maternity care, it is no wonder that the entire nation, but especially states like Kentucky with large rural populations and few care providers are seeing large numbers of preterm deliveries and cesarean births.
Homebirth is no longer an option for many of the women in our region as there are no practicing midwives who are regularly attending homebirths in the area any longer. The state of Kentucky hasn’t issued licensure for homebirth midwifery practice in many years despite the states long tradition of providing quality midwifery care and training nurse midwives. At present, Kentucky is listed as a state where direct-entry midwifery care is prohibited by statute, judicial interpretation, or stricture of practice by the Midwives Alliance of North America. You can see the legal status of midwifery care in each state on the MANA website, where Kentucky and only 12 other states have a white or “illegal” status. Homebirth is not illegal in the state of Kentucky, it is just that prohibition by statute, judicial interpretation, or stricture of practice is in place making it difficult for midwives to attend births and mothers to find a midwife within distance willing to attend.
Midwifery has grown steadily in the US since the days of Mary Breckenridge, with particularly marked growth in the past fifteen years. Since 1990, the number of births attended by certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States has more than doubled. This growth is supported by published research demonstrating that CNMs/CMs provide high-quality care with outcomes comparable to or better than other providers, high levels of patient satisfaction and lower costs due to fewer unnecessary, invasive, and expensive technologic interventions. For more information, please see
Statements like this make it obvious to me what the solution to our problem is – support of our state government of homebirth and birth center midwifery care for the rural women of the state. Supporting midwives who have small local maternity care practices and who are more than capable, trained to attend births through their extensive experience in all manner of births, and highly educated is the key. These midwives could then work alongside obstetric physicians so that both low-risk and high-risk pregnant women can receive quality maternity care as close to home as possible for their situation.
Why not create legislation that would allow midwives who have completed higher education, apprenticeships, and have been certified by national midwifery certifying organizations to offer care in the home and birth center a standard in the state. If we see that optometrists who have not been to medical school as capable of seeing to basic surgical procedures of the eye, in the name of improved rural health, can we not see that a midwife who has been through a midwifery program, passed exams, has attended births, and is confident in her ability to resuscitate an infant if necessary and attend to any other emergency that may arise in a expedient manner as capable of attending to the safety of a laboring woman and the safe birth of her baby? Birth being a normal physiological process and not a irregularity or diease, and attending birth being a safeguarding of a normal life event and not a performing of a surgical procedure to fix an illness.
Support homebirth and birth center midwifery care for the state of Kentucky!!!