The Truth About Home Births

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.