The ‘State’ of Midwifery: Pushing for Legalization

This post is one in a series of pieces RH Reality Check is publishing to highlight National Midwifery Week 2010 (Oct 3- 9).

Women want out-of-hospital maternity care, and they deserve legal access to midwives trained to provide it. In 23 states, Washington D.C., Puerto Rico, and Guam, Certified Professional Midwives (CPMs) face prosecution for serving women who have decided not to give birth in a hospital. Families in these states are forced into an underground economy of providers whose training and credentials could be difficult to ascertain, and are left without any means to report a practitioner who lacks adequate skills. If they do opt to hire a midwife who is practicing illegally, smooth and efficient transfer to a higher level of care can be compromised in the event that it becomes necessary, putting mothers and babies at risk. That’s why more and more states, pushed by consumers and their allies who are part of The Big Push for Midwives Campaign, are passing legislation to license CPMs.

No federal law, Supreme Court decision, or Constitutional amendment can ensure that we have access to the maternity provider of our choice, because licensing and regulation of health professionals occurs at the state level. The Big Push for Midwives engages with consumers in state-by-state efforts to secure a path to legalization and integration of Certified Professional Midwives. Advocates have been on the ground doing this work for years, and are gradually achieving success. Groups like the Alabama Birth Coalition, Ohio Families for Safe Birth, North Carolina Friends of Midwives, the Coalition for Illinois Midwifery, and Massachusetts Friends of Midwives, and others, are tireless grassroots organizers for women and families who chose to give birth outside of the hospital.

Like other movements for social and reproductive justice, securing safe access to choice in childbirth demands solidarity from individuals and organizations not traditionally thought of as allies of midwives and out-of-hospital birth. The mainstream reproductive justice and women’s rights movements must actively stand by women who are demanding our rights as citizens and as mothers.  Aggressive, well funded forces of organized medicine are determined to keep Certified Professional Midwives  underground, threatening women’s autonomy and the public’s health.  This includes the American Congress of Obstetricians and Gynecologists (ACOG), a self-proclaimed “advocate for quality health care for women,” and the American Medical Association (AMA), organizations that wield their reputations and considerable financial influence over state legislators to keep birth in the hospital and make women outlaws.

The medical journal The Lancet recently published an editorial that concluded “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.” This is a familiar message to reproductive health activists: women don’t have the right to value our own lives when babies are involved. And, if the opinion of some doctor or judge about the wisdom of a particular woman’s choice for maternity care differs from her own, she may be forced to accept medical treatment that she doesn’t want or need.

Punitive attacks on women’s rights in birth are not the sole province of the medical establishment. Predictably, and tragically, paternalistic enforcement comes from many sources.  Child protective services in Illinois and Ohio have seized custody of the newborn babies of women who exercised their right to choose home birth with midwifery care — even though the babies born at home were perfectly healthy.  Families have lost custody of their children or faced CPS investigations simply because the mother gave birth at home with a midwife in a state where her legislators have failed to regulate and license Certified Professional Midwives.

Whether or not state legislatures respect the wishes of their constituents and vote to legalize CPMs, women will continue to choose home birth. So long as midwifery remains illegal in so many states, and even in our nation’s capital, these assaults on our rights will continue.  This is  why licensing and integrating CPMs, trained and experienced experts in out-of-hospital birth, makes sense for American women. Happy Midwifery Week, everyone. Won’t you join us?

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  • jicm

    Many thanks to Rebecca Spence from those of us on the ground in Alabama for her insightful post.  Recent numbers from the Centers for Disease Control and Prevention indicate that the percentage of out of hospital births in Alabama has increased by over 18%.  This in a state where there are no legal or regulated care providers to attend families choosing out of hospital birth!  It is of utmost importance that Alabama’s (and North Carolina and Massachusetts and Ohio and Illinois and . . . ) legislature step away from the influence of medical special interests and recognize the need to provide Alabama families with legal access to the quality and cost-effective care that CPMs provide.  We here at the Alabama Birth Coalition won’t rest until they do! Onward.

  • dw

    Thank you Rebecca for this article, this is such an important issue to so many women in our country. We need CPMs legalized in all states, I drove over an hour to another state while in active labor just so I could have the out-of-hospital birth that I knew was best for my family with my wonderful certified midwife.  CPMs are the ONLY professioinals extensively trained in out-of-hospital births and maternity care, let’s allow them to do their job!

  • bpotter

    As a CPM in Virginia, a state that went from illegal to legal 5 years ago, I can personal attest to the improvements in collaborative care in my practice since licensure. Women in VA now have access to diagnostic screening and medical consultation as part of the process of evaluating appropriateness for midwifery care and out of hospital birth.

    In Time Magazine’s recent article, American Women: Birthing Babies at Home,,9171,2011940-4,00.html#ixzz0zKAaDJXi Catherine Elton discusses the “battle over birth” between midwives and obstetricians. As she reviews the recent skirmish related to a controversial meta-analysis by Dr. Joseph Wax published in the American Journal of Obstetrics and Gynecology that throws the safety of home birth into question, she highlights the primary factor where the US fails in providing high quality maternity care to women: collaboration.

    If this truly is a battle, then women and babies are the collateral damage. It is unacceptable for US obstetricians to point to the lack of timely access to hospital care for women choosing to labor at home when those same obstetricians refuse to adopt integrated collaborative systems like those utilized by countries that support out of hospital delivery and have better outcomes in maternity care as a whole.

    US healthcare policy makers need to keep their eye on the prize: better outcomes for mothers and babies.

  • andtheivy


    How dare anyone make it a crime to have your child at home! 

    As a woman who grew up in the UK, I find it astonishing that some American States criminalise home births. It’s totally normal for for British women to have home births and they can often choose the method; my younger brother was born in our bath! I was under the impression that it was safer to have a home birth, because hospitals are more chaotic and there’s always the risk of hospital born bugs. 

    In the UK every pregnant woman is assigned a midwife early on in her pregnancy and one of the first things she’s asked is whether she wants a home birth or a hospital birth. Of course it’s not always possible for mothers who want a home birth to have one. I, for example, was too premature. But there’s no problem if you opt for a home birth and circumstances change at the last minute. In any case it’s considered a mother’s prerogative to decide if she wants to risk a last minute rush to hospital.

    I know there are many things that account for maternal mortality, but it’s worth law makers considering that despite many states mandating hospital births there are 38 countries with fewer maternal deaths than the US:

    I always took the right to choose where you gave birth for granted, I hope that one day all American women will too.


  • smjesq

    Since the effect is pretty much the same, it’s understandable to interpret Rebecca’s blog as indicating that home birth itself is illegal or criminally prosecuted in the US.  In strict fact, no state expressly makes home birth illegal or imposes criminal penalties on women or families that opt for out-of-hospital birth.  What is illegal in 23 states, DC, Puerto Rico, and Guam is the practice by the midwife.  If a Certified Professional Midwife in one of these jurisdictions is reported to have attended an out-of-hospital birth, that CPM could get arrested and be charged with a crime.  As a result, women who wish to give birth at home or in a birth center in those jurisdictions have difficulty finding a midwife willing to attend them for the birth, have no state agency to check with to make sure the midwife is a CPM and is qualified, and can be penalized for having participated in a birth attended by an illegal provider by such problems as harassment by child protective service agencies, or by bureaucrats who issue birth certificates. 

    Two years ago, however, at the prompting of ACOG, the AMA passed a resolution in which it committed to develop and support legislation that WOULD make home birth illegal. 


  • dcgale

    Having had two beautiful home births in Alabama with midwives who were willing to risk prosecution for me, I can speak from experience when I say I LOVE midwifery care.  There are some wonderful OB’s out there but few, if any of them, have the ability to spend an hour with a pregnant woman at each pre-natal visit.  That hour, usually spent lying down on a cozy bed or couch, creates a sense of trust and well-being that cannot be matched by a medicalized office visit.   Unlike most OB practices who rotate on call doctors daily, with midwifery care there is no question who will be with you when you are ready to give birth.  That knowledge is priceless and a great source of comfort to a birthing mother.   

    Pregnancy and birth are normal.  For healthy women who have healthy pregnancies, out of hospital birth can be a wonderful option, assuming they have access to trained professional midwives.  I find it ridiculous that my own state refuses to recognize the quality of care that CPM offer and with that refusal, forces women to drive across the border or find an “underground” midwife to assist them with their birth.   

    We are fighting the good fight here in Alabama and really appreciate the shout out for Alabama Birth Coalition!   

  • pmaurath

    Thanks for this excellent summary of state of affairs surround home birth in the U.S.  Making out-of-hospital birth safe for moms and babies requires that ALL states adopt regulatory statutes that will allow for the licensure of CPMs.  We still have an uphill battle ahead to ensure access for all women in the United States.  Beyond the regulatory requirements, the U.S. needs to develop a fully integrated maternity care system so that mothers and babies can enjoy the high quality midwifery care found in other first world countries.  Thank you Rebecca for bringing this issue to front and center during Midwifery Week.   

  • pmaurath

    Thank you for the additional comments, including the cite of the Time Magazine article, the controvery over Dr. Joseph Wax’s article and keeping the health care system focused on the stellar outcomes that are the result of quality midwifery care in a home setting, within a fully integrated maternity care system.  Even though this is only a dream for many women, Midwifery Week is a good time to celebrate both our progress and the work that remains to be done.

  • thought-crimial

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