While another profession might have the popular reputation of being the world’s oldest, you can make a strong case that midwifery is a more realistic contender for that title. The tradition of caring for pregnant women and delivering babies in homes or community spaces is ancient the world over. And it’s present today, in the providers who practice within an American medical culture in which 99% of births take place in hospitals, presided by OB/GYNs.
Jessica Mattingly, a doula from Blue Springs, MO, notes that midwifery-assisted home birth can foster the understanding that "birth is a normal, celebrated, empowering experience for a woman and her family." And, she adds, "This is not done at the sacrifice of safety for mother and baby, but at the enhancement of it. Midwives and mothers can be and are able to identify the rare cases when medical intervention is needed and can seek collaboration and assistance."
The Fight for Licensure
While dozens of professions drew their numbers together in widespread licensing systems in the last century, midwifery was not among them. While the reasons for this are unclear, it may coincide with the rise of obstetrics in the early 1900s, which seemed to be a competitor to midwifery. The profession pitched more sanitary and better-educated doctors, and that message resonated. By 1955, one percent of American births took place at home, the same rate that stands today.
The lack of licensure is a sticking point for a profession that seeks to provide high-quality, evidence-based care to women, because midwifery skeptics point to it as evidence that the practice is unsafe and unpredictable. Critics claim that its apparent lack of regulation indicates that midwifery unnecessarily endangers both the mother and the baby.
Today you need a license in the U.S. to practice psychotherapy and cosmetology, to drive trucks and to be a mortician — but not to minister to laboring women in homes or in birthing centers. Or at least, not quite: Twenty-one states, including Wisconsin, Montana, and, very recently, Missouri and South Dakota, accept the certified professional midwife credential (CPM) for direct-entry midwife licensure. ("Direct-entry" means that standard midwifery training is recognized as sufficient to practice; the CPM isn’t expected to secure an additional medical degree.) CPMs are backed by the North American Registry of Midwives "to provide out-of-hospital maternity care for healthy women experiencing normal pregnancies," according to Steff Hedenkamp of the advocacy organization, The Big Push for Midwives.
CPMs complete training that lasts three to five years and requires hours in birth observations, classrooms, and clinics. CPMs also pass a national board exam that includes a clinical assessment, out-of-hospital training, and continuing education and re-certification every three years. The CPM is recognized by the American Public Health Association as a basis for licensure.
But while CPMs are certified in their profession and practice across the country, they’re not necessarily licensed. Licensure is up to boards that are set up on a state-to-state basis, and it is here that things get complicated. Certification by itself doesn’t offer legal protection or permission to practice. When a state makes licensing available, it protects the midwife from criminal charges for practicing, even at the highest CPM standards. It’s also likely to increase its number of active midwives, and those midwives will be more accessible to citizens via public awareness and, potentially, insurance reimbursement.
In more than half the U.S. states, midwives are vulnerable to prosecution for practicing medicine without a license. In 2006, an Indiana midwife who had overseen 1,500 births was prosecuted for just that when a baby she delivered didn’t live. The law that could have put her in prison for eight years, and ultimately put her on probation, still stands. Midwives who practice in the District of Columbia, Georgia, Hawaii, and many other states face the same threat. Yet they’re unable to receive licenses in states that don’t recognize midwifery as a viable profession and, rather, see OB/GYN care in hospitals to be the appropriate route for laboring women.
Traditional Medical Organizations Oppose Home Birth
At its 2008 annual meeting in Chicago last month, the American Medical Association passed a resolution opposing home birth. While it didn’t directly oppose direct-entry midwifery, it cited the "twenty-one states (that) currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay" midwives)…" as cause for its challenge to home birth.
The AMA resolution quoted the American College of Obstetricians and Gynecologists in saying that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."
For its part, ACOG reiterated its opposition to home births last February:
ACOG acknowledges a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births… Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.
While the AMA and ACOG are more accepting of midwives who work within hospitals, or in birthing centers that partner with OB/GYNs, the opposition to home births and "individuals who provide home births" equates into an invalidation of midwifery as a whole. Midwifery is fine, the implication goes, so long as it is safely within the realm of traditional hospitals, OB/GYNs, and nurses.
Physician disapproval of direct-entry midwifery assisting in home births resonates with the experience of California mother Alexis Aherns.
"When I told my final doctor later in the pregnancy that I was planning a home birth, he told me he didn’t recommend that, and added that he had seen plenty of women who made that choice show up with dead babies," Aherns said. "It was such a ridiculous statement that it actually didn’t even faze me." Despite her doctor’s predictions, Aherns delivered a healthy child at home with the assistance of a midwife.
ACOG’s position on home birth is one that Mattingly challenges as "terribly hypocritical and a violation of the ACOG Code of Professional Ethics which has as an ethical foundation ‘the respect for the right of individual patients to make their own choices about their health care."
The original AMA resolution last month cited the popularity of Ricki Lake’s recent documentary, "The Business of Being Born," which features her own birth experience as a catalyst for its resolution. Due to popular outcry, however, the AMA soon voted to delete references to Lake and the documentary from its resolution, while maintaining its opposition to home birth.
Though AMA, ACOG, and others skeptical of midwifery and home birth declare their concern for the well-being of the laboring mother and her baby, numerous reports indicate that home births are safe and minimally intrusive.
The British Medical Journal surveyed the 5,400 North American women who had home births with a CPM in 2005. No mothers died and five babies died, or .09 %. In context, the U.S., where nearly all births take place in hospitals, ranks 37th in world infant mortality; there are 6.37 deaths for every 1,000 live births, a rate behind South Korea and Cuba, according to the CIA World Factbook. The U.S.’s infant morality rate is second-worst in the developed world.
The journal survey also found that twelve percent of the home births were transferred to a hospital. Caesarean sections among these women were one-fifth the level of comparable groups who had hospital births.
A recent article in Florida’s St. Petersburg Times quotes the AMA’s citation of a study that compares a 1.7 per 1,000 death rate for babies born in hospitals and a 3.5 per 1,000 rate for those born at home. Home birth advocates charge that women should have the ability to choose what risks they want to face; many see the high rate of c-sections, drugs and labor inductions in hospitals as equally risky. They also point to other research that describes home births as being at least as safe as hospital births.
Doctors and Midwives React to the AMA
Dr. Henry Dorn of High Point, NC, is one OB/GYN — and former AMA member — who questions the recent obstacles to widespread licensure for midwives. Dorn operates a gynecology practice that offers midwifery services.
"I feel that (the AMA’s) statement may stem from a combination of ignorance or avoidance of the facts regarding out-of-hospital birth by skilled attendants, and perhaps a desire to protect the business interests of the physician community,"
Dorn said. "This is not to say that AMA members do not care for their patients’ best interests, but only that given the current medical climate, it would not be surprising to see those outside pressures affect [their] conclusions."
Dorn expects the resolution to "discourage another generation of doctors from considering alternatives to highly medicalized birth, as most feel that any statements by the AMA should be viewed as gospel."
Mattingly wonders if the root issue is that many doctors fear what they don’t know. "Very few doctors have seen a birth without any medical intervention," she said. That means, "Most have never ever seen a normal birth."
Despite its discouraging tone, Coral Slavin of Well-Rounded Maternity Center in Menomonee Falls, WI, thinks the resolution will have an unexpected effect.
"Ironically, I think that the AMA stand against out-of-hospital birth has only driven more people to view Ricki Lake’s documentary and spurred more questions. I don’t see how lawmakers morally could ban out-of-hospital birth without proof of the alleged dangers," Slavin said.
Dr. Elizabeth Allemann, a physician from Harrisburg, MO (she is not an AMA member) found another reason to be positive: "Honestly, there’s a little bit of a relief in having them actually make the statement. Now we no longer have to try to convince legislators that organized medicine is opposed to home birth and midwives, and can’t be a good-faith partner in designing legislation."
If Midwives and Physicians Could Collaborate
The stance the AMA and ACOG have taken against non-hospital births, alongside the de facto stance taken by states that don’t allow for midwife licensure, diminishes a culture of collaboration among doctors, midwives, and expecting women. While the two professional organizations detach themselves from CPMS, many midwives and home birth advocates recognize the important role OB/GYNs play in their vision for a renewed culture of birth.
Comparatively, home births are actively encouraged by U.K. governments, and in Edinburgh in particular. Nicola Goodall is an Edinburgh doula who reports that OB/GYNs and midwifes are partnering in an effort to respond to more babies being born than there are hospital units to accommodate them; Goodall said the collective goal is to increase home births by 800%. It’s an ambition that also translates into making midwifery an appealing and accessible profession.
"Midwives are registered here and they work alongside doctors and hospitals," Goodall said. "All women giving birth in the UK get midwifery care, but they may get it alongside doctors if they have a special need (such as) a medical problem like diabetes."
Stateside, many are working to diminish the unfriendly competition that dates back to the development of obstetrics one hundred years ago.
Steff Hedenkamp of The Big Push outlines the way the AMA and midwives could collaborate:
We welcome the AMA joining the Big Push as we work to bring together a national effort that is creating meaningful consumer protections and a new model for the U.S. maternity care system — one into which midwives are fully integrated. We welcome the AMA applying its vast resources to helping create a maternity care system that supports people from all walks of life from all over the U.S.
For their part, midwives often see the benefits of working with allopathic providers.
"We know that this partnership is needed to create that optimal environment for all mothers and babies," said Dr. Allemann.