To License or Not: States and Midwifery

TO LICENSE OR NOT: STATES AND MIDWIFERY

Volume 28, Issue 502 October 29, 2007

Tara Lubin

Throughout the centuries, midwifery has often been a controversial profession. Today, the issue is arising in some states, as lawmakers debate the circumstances under which midwives should be allowed to practice. One particularly controversial topic is whether certified professional midwives (CPMs) should be licensed.

There are a number of different types of midwives, with different levels of education and credentialing, from nurse-midwives (who are nurse practitioners) to lay midwives (who often get their training by serving long apprenticeships). CPMs fall somewhere in the middle, as they don’t have formal nurse training but have met the standards for certification set by the North American Registry of Midwives (NARM), the professional association of all midwives.

CPMs contend that they are fully qualified to independently guide low-risk women through the natural events of pregnancy, birth and postpartum care. Because they see birth as part of a natural process, and not as a part of the “healing arts” practiced by medical professionals, they don’t need medical training, they add.

As for safety, they point to the largest home birth study, published in 2005 in the British Medical Journal. Planned home births with CPMs were associated with lower rates of medical intervention than those of low-risk hospital births in the United States, and with good outcomes overall. There were economic advantages as well—an uncomplicated hospital birth costs on average three times as much as a similar birth at home with a midwife, according to the study.

But the American College of Obstetricians and Gynecologists (ACOG) disputes the scientific rigor of the BMJ study. In a 2007 statement, ACOG said: “Labor and delivery is a physiologic process that most women experience without complications. Ongoing surveillance of the mother and fetus is essential because serious intrapartum complications may arise with little or no warning...In some of these instances, the availability of expertise and interventions on an urgent or emergent basis may be life-saving for the mother, the fetus or the newborn and may reduce the likelihood of an adverse outcome…”

The controversy over CPMs illustrates the wider issue of training and oversight for professions that are related to the health and well-being of people—but are not necessarily medical. Take long-term care, for example. Patients in nursing homes have their care directly overseen by nurses and physicians. Should the workers who provide home- and community-based care also have their efforts overseen by medical practitioners? Or should such aides be allowed to work independently, perhaps after passing a training course?

Wisconsin and Lawsuits

The battle over licensing midwifery was played out last year in the Wisconsin Legislature. Midwives have been practicing in Wisconsin for years, but they lobbied the Legislature to pass a bill to create a licensing process because they feared that they might be accused of practicing medicine without a license. Across the country, state boards of nursing and others have brought multiple lawsuits alleging that unlicensed midwives are unlawfully practicing medicine. (See: www.narm.org/practiceofmidwifery.htm) The lawmakers complied by enacting SB 477, which creates a licensing process for midwives who are credentialed by the NARM or the American College of Nurse Midwives.

According to bill author Senator Glenn Grothman, the midwives initiated “one of the best grassroots efforts I’ve seen” to get the bill through. “Normally I don’t like licensure of any sort because it winds up in a ‘fence me in’ situation…I think we have far too many licenses out there. But [the midwives] made a real good pitch that they do a good job. Statistically the number of C-sections of low-risk pregnancies by midwives compared to doctors is not even in the same ballpark and of course the cost isn’t as great either. There’s no reason why [people opposed to using a doctor] should be forced into a situation in which they have to use one.”

In Delaware, the midwives were less successful. Representative Pamela Maier sponsored HB 106, which was designed to establish licensure for CPMs, create the Certified Professional Midwifery Council to oversee licensure and remove the requirement of a relationship with a physician, but it was tabled.

“We are the only experts in the country on home birth,” said Susan DiNatale, president of the Delaware Midwives Guild. “It’s a totally different training (from physicians’). We are taught what is normal and what is important to look for. Doctors are taught to anticipate disaster…We don’t anticipate disaster…we’re cautious, however.”

States that have licensed CPMs in recent years include Utah, Vermont and Virginia. States that had bills introduced in the 2007 session included Alabama, Idaho, Illinois, Indiana, Massachusetts, Missouri and South Dakota.

One state that makes extensive use of CPMs and other midwives is New Mexico, which not only requires its Medicaid program to cover all midwifery services, but has lifted the medical malpractice requirement if insurance is unavailable or prohibitively expensive. Recently, the state established a birthing options program to educate Medicaid enrollees about available providers for pregnancy and birth. A state report noted that more than 32 percent of babies born in New Mexico are ushered into the world by midwives—the highest percentage in the country, according to the Center for American Progress, a think tank that supports midwifery.

For more information on midwifery and health-care workforce issues in general, contact NCSL’s Tara Lubin, tara.lubin@ncsl.org or (202) 624-3558.