Nearly a year after the city enacted a controversial law allowing midwives in private practice to deliver babies in a hospitals without a doctor present, only one midwife has applied for such privileges.
Rene Smit, a certified nurse-midwife who works as a labor and delivery staff nurse at the Washington Hospital Center, applied to the hospital in July for the right to deliver babies and was told in November that she must have a doctor present for all deliveries.
"By requiring her physician be present, whether one is needed or not, they're violating the intention of the law which is to give nurse-midwives privileges to the full extent of their education, training, practice and experience," said Susan Jenkins, a lawyer who specializes in health issues and is representing Smit.
Jenkins has asked the D.C. corporation counsel, the city's legal official, for an opinion the hospital's decision.
"I am considered the test case to the new law," Smit said. "There are people watching my situation."
D.C. physicians, backed by the hospitals, strenuously opposed passage of the city's precedent-setting law, saying it would result in lower standards at District facilities. Supporters of the law said it would lower hospital costs by creating competition within the medical profession.
The law gives hospitals the right to design criteria for granting these so-called clinical privileges to individual practitioners but says hospitals cannot bar nurse-midwives from using their facilities.
Many nurse-midwives said they believe that the requirement of the Washington Hospital Center for a doctor to be present at midwife deliveries is an attempt to circumvent the law.
"They are burdening the nurse-midwife with the addition of a phyisician when there are no complications" in the delivery, said Patricia Powell, a certified nurse-midwife who works at D.C. General and is cochairwoman of the legislative committee of the local chapter the American College of Nurse-Midwives, a professional and certifying organization.
"We think that is just a guise for anticompetition . . . . That's more money" the client must pay, she said.
The doctors disagree.
"While a nurse-midwife is highly skilled in delivering a normal birth . . . a normal delivery can become very complicated, very fast," said Dr. Dennis O'Leary, former president of the D.C. Medical Society and dean for clinical affairs at George Washington University Medical Center.
Dr. Robert Collins, the society's current president, added that hospitals have to guard against all possible risks and offer the best possible health care to a patient.
"If there is fetal distress when the baby is in danger , a patient may need an immediate cesarean and nurse-midwives are not trained to do cesarean sections, and it is not a part of their clinical privileges," he said.
Collins said he believes that hospitals should consider requiring that an obstetrician be available at the hospital during the delivery.
In Smit's case, the Washington Hospital Center has required that one of her three backup physicians be present at the hospital during delivery. According to Smit, this would be unnecessary because the physician would not be participating in the delivery and her clients would have to pay a fee to her and a consultation fee to the physician.
A spokeswoman for the hospital said Smit has been admitted to practice but that current hospital rules state that only doctors can deliver babies. "Adjustments will be made so that she can practice here," the spokeswoman said. She added, "The hospital will not do anything that could be perceived to be against the spirit or the letter of the law of the District of Columbia."
Prior to passage of the legislation in late 1983, a midwife could deliver babies only in the home or at a birthing center because hospitals would not extend delivery room privileges to certified midwives in private practice. Nurse-midwives who worked for the Group Health Association and who were on the staffs of hospitals were allowed to make deliveries in hospitals.
With the new law, consumers have the choice of giving a birth at home, at a birthing center or at the hospital, said nurse-midwife Powell.
The law grants hospital access to four other classes of health professionals: nurse-anesthetists, nurse-practitioners, psychologists and podiatrists.