Fierce Debate Over Midwifery Licensure

A friend of mine is expecting her first child and when I last spoke to her she was in the midst of putting her birthing plan together. I have to confess that I was a little alarmed, since this is the same friend who ended up with three binders full of information and a battle plan complete with multiple exit strategies when she got married. But as our conversation progressed I realized that, with so many options to consider and some serious decisions to make, a birthing plan is a pretty good idea.

One of the birthing options many people consider is whether to use a midwife and, as Barbara Kantrowitz and Pat Wingret pointed out in their Newsweek piece The Delivery Debate, making that decision can be very confusing. Beyond the basic medical and personal considerations, some states are debating legislation that may impact access to midwifery care. Here in Missouri, State Senate has been debating Senate Bill 1021, which "changes the laws regarding midwives and the practice of midwifery." The debate over whether to regulate midwifery, how that regulation would take place, and which body would oversee that regulation has been fierce.

Currently, Missouri midwives must have a nursing degree and work under a doctor's supervision — otherwise, they are committing a felony by overseeing the care of a pregnant patient. But Senate Bill 1021 would

"create a 'Board of Direct-Entry Midwives' [midwives who begin their education in midwifery directly rather than after completing a nursing program] within the Division of Professional Registration. The board shall have the power to issue licenses and to suspend, revoke or deny the license of a direct-entry midwife. The board shall develop practice guidelines regarding the practice of midwifery established by the National Association of Certified Professional Midwives, including the development of collaborative relationships with other healthcare practitioners who can provide care outside the scope of midwifery when necessary."

Steff Hedenkamp of The Big Push for Midwives Campaign, a group pushing for the regulation and licensure of Certified Professional Midwives in all 50 states and the District of Columbia, was in Jefferson City, Missouri, during the recent Senate debate. Hedenkamp said that she talked to a lot of Senators and Representatives who support Senate Bill 1021 because they like the compromises made and the way it will address concerns about liability, education, certification and licensing.The bill passed out of committee five to one which is proof, according to Hedenkamp, that there is political will to pass it if it were brought to the floor for an up-or-down vote.

Protecting and defending the ability of certified midwives to provide legal and safe healthcare is an essential part of the reproductive justice movement, as Amie Newman explored in her article A New Life For Midwifery Care. Amie argues that "restricting access to a full-range of health care providers, especially those known to improve health outcomes for maternal and newborn health, is not healthy for women and babies."

Yet those opposed to legislation like Missouri's Senate Bill 1021 claim that protecting maternal and newborn health is also their motivation. As reported by Michelle Munz of the St. Louis Post-Dispatch, the Missouri State Medical Association is lobbying for greater doctor supervision of midwives, stating a concern for public safety.

The group wants midwives to have written collaborative-practice agreements with a physician that will justify regulation by the Board of Healing Arts. An amendment proposed by Senator Graham, D-Columbia, would place the regulation of midwives under that physician registration board. But 24 other states license midwives and the majority of them do so without physician involvement with direct-entry midwives, instead licensing and certifying them through midwifery boards or committees.

Advocates for Senate Bill 1021 point out that regulating midwifery through the Board of Healing Arts would set a dangerous precedent of having one profession regulate another. Hedenkamp feels that the Graham amendment guts the bill and that the physician-based board would simply not issue licenses, effectively regulating midwives out of existence.

As things currently stand, Senate Bill 1021 may not go to the floor for an up-or-down vote. But midwifery advocates pledge to continue the fight. Hedenkamp says that "we will continue to work hard, continue to tell our stories, continue to shine light on and give voice to what Missouri families want: legal access to licensed Certified Professional Midwives in the state, and now."

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  • invalid-0

    I’ve been active in the fight to legalize midwifery in Missouri and I’m so disappointed in Chuck Graham’s behavior with this issue. He is a strong pro-choice supporter, one of the few we have in the MO legislature, (I’m pro-choice too)and it disturbs me that he cannot see that the freedom to choose where, how, and with whom, you birth, is the other side of the choice issue.
    He talks about homebirth mothers as though they were feeble-minded children who cannot be allowed to make these decisions for themselves and must have the state help them. This is exactly the way anti-choice legislators in MO, and elsewhere, talk about women.
    I’m so sick of other people thinking they have even one iota of business being involved in my personal health care decisions.

  • invalid-0

    Most people interested in the issue of midwifery do not understand that certified midwives are very different from certified nurse midwives. Certified midwives themselves are working very hard to create confusion on this point. American women need to know that certified midwives have less education and less training than any midwives anywhere in the industrialized world. They would not be considered adequately trained to work in countries like the UK and the Netherlands where midwives care for most patients.

    In contrast to the claims of midwifery advocates, all the existing scientific evidence to date shows that homebirth with a certified midwife has an increased risk of preventable neonatal death in the range of 1-2/1000. There are studies that claim to show that homebirth is as safe as hospital birth, but they do that by comparing homebirth to high risk hospital birth or to hospital birth in decades past.

    Before states consider licensing certified midwives they should do two things. First they should dramatically increase the educational and training requirements to be on par with European midwives. Second, states should demand a public accounting of homebirth safety statistics from the Midwives Alliance of North America (MANA). MANA has been collecting detailed statistics on all homebirths with certified midwives since the year 2000. MANA has publically offered the statistics to those who can demonstrate that they will use those statistics for the “advancement of midwifery”. Even then, researchers must sign a legal non-disclosure agreement promising not to reveal any data to anyone else. It does not take a rocket scientist to surmise that MANA’s own data shows homebirth with a certified midwife to have an unacceptable risk of death. Women deserve to know this information and states deserve to have this information before contemplating licensure of certified midwives.

  • invalid-0

    The right to have access to certified professional midwives – who ARE qualified professionals to assist healthy, low-risk women give birth outside the hospital – is fundamental to women’s reproductive choice. Control of women’s bodies by medical professionals in birthing in the name of maternal and child health is just another way that women are victimized when they attempt to control their own fertility.

    The quality of care provided by NON-NURSE professional midwives in the U.S. and Canada was demonstrated in a study published recently in the British Medical Journal:

    Advocates are correct in stating that women in all 50 states should have access to homebirth and to non-nurse midwifery care WITHOUT required physician oversight as a fundamental matter of reproductive freedom.

  • invalid-0

    Pamela Pilch:

    “The quality of care provided by NON-NURSE professional midwives in the U.S. and Canada was demonstrated in a study published recently in the British Medical Journal”

    You have just illustrated my point for me. The BMJ study by Johnson and Daviss does NOT show that homebirth is as safe as hospital birth. In fact, it actually shows that homebirth in 2000 had a rate of preventable neonatal death almost TRIPLE that of hospital birth in 2000. Of course, you won’t find that in the paper. That’s because Johnson and Daviss conveniently left out the neonatal death rate for hospital birth in 2000. Instead they compared homebirth in 2000 to hospital birth extending as far back as 1969. They hoped that homebirth advocates would not notice the bait and switch, and, indeed, they didn’t.

    Johnson and Daviss are hardly independent researchers, either. Johnson is the former Director of Research for the Midwives Alliance of North America (MANA). Daviss, his wife, is a homebirth midwife. They managed to leave that information out of the paper as well. The study was commissioned by MANA and the statistics were collected by MANA. The study was financed by money from a homebirth advocacy foundation.

    So two long time public advocates of homebirth undertook a study for the trade union of homebirth midwives using money from a homebirth advocacy organization. They showed that homebirth had an increased risk of preventable neonatal death compared to hospital birth, but tried to obfuscate that fact by failing to even mention the hospital neonatal death rate in the same year.

    It is absolutely imperative that the public understand that the claims of safety by homebirth midwives are NOT supported by the scientific evidence. The only people who believe that homebirth is as safe as hospital birth are homebirth advocates themselves. Certified midwives do not meet the standards of any other industrialized country. Certified midwives are a second, inferior class of midwife. They work very hard to disguise that fact, but even a cursory examination of the requirements for certification show that they are undereducated and undertrained.

  • invalid-0

    The midwifery supporters in MO know very well that CPMs are very different from CNMs, that’s exactly why we are fighting for the legalization and licensure of CPMs. The vast majority of CNMs practice to the same medical model that doctors do, that’s why we want CPMs, midwives trained in out-of hospital births.
    But more importantly, as stated in my original comment, I don’t know why it’s anyone else’s business, least of all Amy Tuteur’s, how I choose to have my children.
    Again, it gets back to the agency of women. We are capable of making our own, informed health care decisions, we don’t need the state or people like Amy, who misses no chance to post her digs at CPMs anywhere and everywhere, telling us we don’t really know what we’re doing. It’s absolutely insulting and infuriating.

  • invalid-0

    Lisa, I haven’t met you, but “you go girl!” Thanks for your posts, I couldn’t have said it better myself!