Jennifer Crook is a trained and certified midwife living in Birmingham, Alabama, who has presided over about 200 home births. But to do so, she and her pregnant patients had to drive two hours across the state line to Tennessee.
The reason for the border crossing was simple: Alabama is among 21 states that do not license midwives who deliver babies outside of hospitals. And practicing midwifery without a license in Alabama wasn’t worth the risk.
“It’s certainly not a place that you want to practice as an illegal midwife — because the state has prosecuted in the past,” said Crook, whose license to practice is from Tennessee. She began her training in 1997 and practiced until 2012. Now she lobbies for licensing in Alabama.
By not allowing midwives to lawfully perform out-of-hospital births, Crook said, states like Alabama are not just hampering their ability to practice their profession. They are depriving expectant mothers who may not have easy access to obstetric care in a hospital of a safe and, for some, desirable method of delivery.
Some critics, including doctors’ organizations, refute that home deliveries attended by midwives are indeed a safe alternative to hospital births.
But what’s clear is the state regulatory terrain for midwives poses a problem for consumers when the nation is experiencing an increase in the number of births taking place outside hospitals, usually in homes or freestanding birthing centers. The percentage of out-of-hospital births crept up from 0.87 percent of all births in 2004 to 1.36 percent in 2012, according to the Centers for Disease Control and Prevention.
Women often choose out-of-hospital births so they can deliver their babies in an intimate, familiar setting where they think their wishes for natural childbirth are more likely to be honored. Home births are most popular in rural states, where women often live at a distance from obstetric care or where midwives are more accepted by the medical community.
Alaska has the highest percentage of out-of-hospital births (6 percent), followed by Montana (3.9 percent), Oregon (3.8 percent), Washington (3.4 percent), Idaho (3.4 percent) and Pennsylvania (3.1 percent).
Midwives in Alaska and Pennsylvania attend out-of-hospital births even though those states do not issue them licenses, according to groups that represent midwives. Two states, Alabama and Nebraska, not only don’t license midwives who perform home births, they also specifically prohibit the practice.
Types of Midwives
Generally speaking, there are two types of midwives — certified nurse-midwives and certified professional midwives like Crook.
Certified nurse-midwives attend births almost exclusively in hospitals or in hospital-run birthing centers. They are registered nurses with bachelor’s degrees who have completed graduate training accredited by the Accreditation Commission for Midwifery Education and have passed a certification test administered by the American Midwifery Certification Board. They are licensed in all 50 states and the District of Columbia. There are at least 11,100 certified nurse-midwives practicing in the U.S.
Certified professional midwives attend to births outside hospitals, in homes or birthing centers unaffiliated with hospitals. Generally, they cannot administer drugs, including painkillers associated with delivery, other than antibiotics or medication to prevent hemorrhaging. In becoming certified professional midwives, they do not need a college degree. They can enter the profession through a clinical internship with someone who already holds a license or an educational program that may or may not be nationally accredited. They must also pass a clinical evaluation and a written test administered by the North American Registry of Midwives (NARM). There are about 2,600 certified professional midwives practicing.
There also is a third, though much smaller, group of midwives — certified midwives, who are not nurses but are college graduates who undergo the same midwifery training and testing as nurse-midwives. Only Delaware, Maine, New Jersey, New York and Rhode Island license them, though most of the approximately 100 licensees are in New York.
Like nurse-midwives, certified midwives practice mostly in hospitals. In 2014, 94 percent of the births attended by certified nurse-midwives or certified midwives were in hospitals, according to the American College of Nurse-Midwives.
Fight Over Licensing
NARM and other groups representing certified professional midwives argue that the lack of state licensing leaves patients at sea when judging the qualifications of midwives they may want to hire.
“It’s a huge consumer issue,” said Ida Darragh, NARM’s executive director. “Expectant mothers want midwives whose qualifications are recognized by the state. And they want their midwives to be legal, not underground.”
Midwives have been prosecuted in Alabama, Connecticut, Illinois, Kentucky, North Carolina and South Dakota, usually for practicing medicine without a license, Darragh said.
The certified professional midwives’ groups have made steady but slow progress. Indiana approved licensing for their profession in 2013, Rhode Island in 2014 and Maryland in 2015.
But efforts have faltered in other states in recent years, including in Alabama, Idaho, Illinois and South Dakota, often as the result of opposition from groups representing doctors, including obstetricians and nurse-midwives.
The lack of licensing also hampers reimbursement for midwifery. As it is, Medicaid agencies in only a dozen states authorize payment for certified professional midwives, according to the National Association of Certified Professional Midwives.
Part of the opposition reflects concerns about the safety of home births. A 2014 study in the American Journal of Obstetrics and Gynecology found that the rate of neonatal deaths of midwife-attended home births are four times higher than for midwife-attended births in the hospital and seven times greater for first-time deliveries.
With all the complications that can arise in childbirth, choosing to have a baby at home makes no sense, said the study’s chief author, Amos Grunebaum, a professor at Weill Cornell Medical College and the chief of obstetrics at NewYork-Presbyterian Hospital.
“You have many options at hospitals — pain control, intravenous medication, fetal monitoring, a team available if something goes wrong with mother or baby, blood transfusions,” Grunebaum said. “None of these are available at home births. Those are a throwback to old times. It is unprofessional to tell women they can deliver at home when all these options are available in the hospital.”
But a 2014 study in the American College of Nurse-Midwives’ Journal of Midwifery & Women’s Health found healthy outcomes for the vast majority of midwife-attended home births, with high rates of babies born at healthy birth weights and with few low scores on Apgar tests, used to evaluate the health of newborns. The babies also had a high rate of successful breast-feeding.
A 2007 study commissioned by the Washington State Department of Health determined not only that midwife-attended deliveries for low-risk pregnancies are safe, but also that they result in significant cost savings over hospital births.
But Amy Tuteur, a former obstetrician and onetime clinical instructor of obstetrics and gynecology at Harvard Medical School, argues that certified professional midwives are inconsistently and inadequately trained and that their practice should be abolished.
“They would not be able to practice midwifery in any other industrialized country,” Tuteur said. “It’s basically a big public relations ploy.”
She bases her argument partly on the fact that certified professional midwife training, unlike the training of certified nurse-midwives and certified midwives, isn’t in accord with all standards of the International Confederation of Midwives, a worldwide organization that promotes best practices in midwifery.
But NARM’s Darragh said midwives in other parts of the world are called on to do more than care for expectant mothers and newborns. They provide general primary care, administer medications and even perform abortions.
Certified professional midwives in the U.S. have no need for that kind of training and should not be penalized for not having it, Darragh said. “Our training is very well structured and comprehensive,” she said.
Certified professional midwives groups recently entered into an agreement with other midwife organizations, which could enhance their chances of gaining licensing.
The deal recommends that any new states that license them require they be educated by an accredited midwifery teaching institution. Separate apprenticeships would no longer suffice.
The American College of Obstetricians and Gynecologists, which helped broker the deal, said that would remove one of its objections to licensing — although the group would also insist on other restrictions in state laws, including limiting certified professional midwives to low risk pregnancies.
Crook, the midwife who now lobbies for licensing in Alabama, is critical of the agreement, however. She said it would create “unnecessary hoops” for midwives to jump through to get a license. Still, Crook, who has a master’s degree in public health, said states like Alabama need to allow midwives to practice.
The state ranks near the bottom of the country in pre-term births, low birth weights and infant mortality. And only 29 of Alabama’s 67 counties had hospitals with obstetric services as of 2014. “Midwives,” she said, “are actually part of the solution.”
This story was produced by Stateline, an initiative of The Pew Charitable Trusts.