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Many midwives work in the shadows as they await proper state regulation of home births

And it's putting pregnant people at risk.

credit: getty images
credit: getty images

Planned home births have increased over the past few years, but several states are only on the fringe of governing the practice — and the lack of regulation is hurting pregnant people.

Expectant individuals with healthy backgrounds and no medical risk factors often choose to deliver their babies in their homes. But the practice is contentious. The American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) both oppose home birth, citing safety issues. Those in favor of home births have been pushing for increased regulation to ensure adequate safety standards are met and to bring midwifery into the medical mainstream.

Today, 17 states and the District of Columbia lack sufficient regulation to ensure certified professional midwives (CPMs, or midwives who deliver home births) are licensed. Many unlicensed midwives work anyway and, in doing so, often put mothers at risk of poor treatment.

Home births only represent a small fraction of overall births, but the number is rising every year. According to the Centers for Disease Control, more than 35,000 births occurred at home in 2012 (roughly 4 million babies were born in the United States in 2012). Since 2004, home births have been increasing steadily.

In most home birth cases, a CPM, certified by the North American Registry of Midwives (NARM), will deliver the baby and guide the mother through prenatal and postpartum care. While most CPMs have undergone the required training, their subsequent certification doesn’t equal licensure. And efforts to increase regulation have been met with opposition by much of the medical community.

Legislative roadblocks force midwives underground

In Illinois, about 1,000 babies are born at home every year, but there are only an estimated 25 known CPMs in the state, according to industry officials.

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Illinois state lawmakers introduced the Home Birth Safety Act in February to provide a path to licensure, but the bill has since failed to make it out of Senate committee. The measure’s language was formulated by a group of national organizations, called the US Midwifery Education, Regulation and Association (US MERA), that passed standards in 2015 based on conversations and compromises with national obstetrics organizations, which have long demanded educational and regulatory practices for midwives.

The American Academy of Pediatrics, based out of Illinois, came out staunchly against the legislation in 2016, as it has for many years, despite the new additions to the bill from the compromises of the national US MERA standards requiring new CPM applicants to complete educational and training programs by Jan. 2020. The standards also include a national midwifery exam.

Illinois moms and midwives protest the Illinois Chapter of the Academy of Pediatric’s  opposition to the Home Birth Safety Act. (Courtesy of Barbara Belcore-Walkden)
Illinois moms and midwives protest the Illinois Chapter of the Academy of Pediatric’s opposition to the Home Birth Safety Act. (Courtesy of Barbara Belcore-Walkden)

Opposition to home births is common in the medical community, largely due to concerns over safety. In 2015, Amos Grunebaum, director of obstetrics, and Frank Chervenak, obstetrician and gynecologist-in-chief, at Weill Cornell Medicine in New York, conducted a team study in which researchers found that midwife-attended planned home births had numerous risk factors and that those risk factors were higher among midwives without the proper certification.

In an Op-Ed for the New York Times, Grunebaum and Chervenak wrote, “Midwife-attended deliveries at home see significantly higher rates of stillbirth, infant mortality within the first month of life, and babies with significant neurologic damage when compared to mid-wife attended deliveries the hospital.” He added that two-thirds of home births are delivered by “midwives who are not properly credentialed.”

Safety concerns are one of the primary reasons that advocates are seeking regulation to ensure proper certification.

Barbara Belcore-Walkden, president of the Illinois Council of Certified Professional Midwives, has been a practicing CPM for 11 years, and is also licensed in the bordering state of Wisconsin. “I’ve sat in Illinois Senate hearings talking about the difference of how I am treated in Illinois versus Wisconsin. Doctors and nurses in Wisconsin have learned and been eager to collaborate with CPMs,” Belcore-Walkden told ThinkProgress.

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Belcore-Walkden said that, in Illinois, the common encounter with obstetricians and pediatricians involves miscommunication about midwives’ education. “They seem to think there’s a drastic risk that moms face in home birth. Any well-trained midwife screens out a mom from home birth when the risks are high. They don’t seem to understand the educational background of CPMs.”

CPMs deliver only low-risk babies, she said, because of the low-tech environment of a home. “Homes and birth centers are not equipped to manage the level of emergency that can occur in a high risk pregnancy,” she added.

An increased demand for home births has put the the state’s glaring lack of licensed midwifery care on full display. Sarah Moore, the legislative liaison for Illinois Council of Certified Professional Midwives, said that her region of the state, known as the Quad Cities, has few CPMs.

“There are no midwives for them to hire, and they typically don’t go to hospitals, so there’s a gap in the maternity care system where women are left vulnerable.”

“Our Amish community is left totally open. There are no midwives for them to hire, and they typically don’t go to hospitals, so there’s a gap in the maternity care system where women are left vulnerable. In 2017, that is unacceptable,” Moore told ThinkProgress.

Things are difficult, especially with the powerful Illinois Medical Society lobbying against midwives, she added.

“I can’t tell you the amount of state legislatures who have told me that they have to side with the state medical society, because that’s how they were elected,” Moore told ThinkProgress. She believes licensure would protect families in her area who hire uncertified midwives without knowing their history.

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“In my area, a family hired someone who called herself a midwife, but this family had no idea what they were getting themselves into. The baby died from something that would have been caught by someone with licensure,” she said.

Illinois CPMs will likely have to wait for another legislative session to try to pass their bill. Other states, like neighboring Iowa, Kentucky, and Oklahoma have their own bills in the middle of legislative processes. CPMs hope that by updating their most recent bills according to language in the US MERA standards, the likelihood of passage will increase.

In 2016, the The American Congress of Obstetricians and Gynecologists (ACOG) supported efforts for licensure for the first time because of the new standards, saying, “It is essential that we send a unified message to legislators, regulators, the public, and our patients that we support nothing less than high quality maternity care.”

State licensure policies would “protect public safety”

In Massachusetts, where licensure efforts have been lagging in the legislature for many years, a hearing was recently held on an out-of-hospital birth access and safety bill. The bill’s passage would create a Board of Midwifery under the Department of Public Health to oversee licensure and require CPMs to be credentialed through the standards set by US MERA.

There are only around 60 CPMs in Massachusetts, but this is a rough estimate. It’s not possible to keep track of all licensed CPMs since licensure status can change overtime, said Ida Darragh, executive director of NARM. But improvements to state licensure policies would change that, allowing states to keep track of CPMs, by specifically allowing offices of professional licensure to have a list of who is licensed.

“In public health, that’s something we would favor,” Gene Declerq, assistant dean of the Boston University School of Public Health, told ThinkProgress.

“I’m pleased to see Certified Professional Midwives seeking state supervision and regulation in order to be able to ensure that those attending home births are as competent as possible with an oversight mechanism that can help protect public safety,” Declerq said in submitted testimony to the public hearing in Boston.

“We don’t have opposition like we had before from the Massachusetts Medical Society.”

“We’re waiting to hear back from the public health committee, and see what their recommendation is,” Ann Kilroy, a Massachusetts CPM who is involved in the legislative effort, told ThinkProgress. “We don’t have opposition like we had before from the Massachusetts Medical Society, because we are in compliance with the College of Obstetricians and Gynecologists, as long as we meet certain educational requirements.” This is the first time the CPMs have had no opposition from the medical community.

Kilroy has been a CPM for 17 years, and has had five of her six children at home. “I’m on call all of the time for prenatal and postpartum visits,” she said.

If complications arise during care, which happens rarely, Kilroy has relationships with nurse midwives at local hospitals and obstetricians who can take a patient in the event of something like a breech delivery, or a patient with high blood pressure.  

“We don’t have enough obstetricians and nurse midwives who want to do it,” she said, discussing the stigma against home births. “Licensing might make them more likely.”

The increasing popularity of home births has much to do with its cost. Home births are much cheaper than hospital births, especially for those without insurance. According to several interviews conducted by ThinkProgress with CPMs nationally, the range runs between $3,000 to $6,000 for prenatal, delivery, and postpartum care. Kilroy’s runs near $4,500.

“It’s a great deal for consumers,” she said.

Although the Massachusetts bill does not mention public insurance coverage, CPMs across the United States hope their states will eventually grant public insurance reimbursement. Vermont and New Hampshire are among 14 states that provide Medicaid reimbursement to licensed certified professional midwives.

Still, home birth remains unaffordable for many low-income individuals.  

“I get calls from people who want to give birth at home, but can’t afford it. Much of our clientele pays out of pocket. Coverage is a big reason for access to care,” Kilroy said.

The road ahead

Recently, more states have passed or are expected to pass licensure legislation, in a growing effort to incorporate midwives into conventional medicine.  

Maine’s legislature passed a midwife licensing bill in 2016, which will go into effect in 2020, and sets new educational and training standards. CPMs will be prohibited from delivering breech babies or twins, and can’t deliver a baby for a woman who has had a previous cesarean section.

Alabama also recently passed its licensing bill, and according to Susan Jenkins, an attorney with activist campaign Big Push for Midwives, Kentucky could be next. There, Jenkins said, the need for CPMs is high, as the state struggles to provide enough nurse midwives to fill the wave of individuals interested in home birth.

In Illinois, midwives plan to keep pushing for the legislation to pass, but may need to wait until the next legislative session. “This language is nationally agreed upon,” Sarah Moore said, “It’s a nationally accredited [midwifery] education. This is everything we’ve always been asked of.”