I have written previously that safer homebirth requires educated, regulated midwives. Anyone who has looked into state midwifery laws in the U.S. has come to the same alarming conclusion: in many states, homebirth midwives are virtually unregulated. If you support uniform midwifery regulations in the U.S. that will make homebirth safer, then
The petition outlines the minimum midwifery regulations every state should have:
Requiring a License - If you need a license to cut hair, why wouldn’t you need one to deliver babies? For midwives who attend homebirths in Oregon and Utah, for example, having a license is completely optional. This makes absolutely no sense. In many other states, direct-entry midwifery is ostensibly regulated, or actually illegal, but midwives are rarely, if ever, held accountable. Requiring a license for anyone who uses the title “midwife” is the first step.
AMCB certification - There are two midwifery certification paths in the United States: AMCB and NARM. Hospital midwives have to be AMCB certified, meaning they have to be a Certified Nurse-Midwife or a Certified Midwife after attending an ACME-accredited school. The ACOG and the AAP only recognize AMCB-certified midwives.
Many states license NARM-certified midwives, such as Certified Professional Midwives, Licensed Midwives, or Direct-Entry Midwives, who can only attend out-of-hospital births.
Judith Rooks, CNM, and past president of the ACNM, has said of CPMs,
“... the PEP route [portfolio process] to certification as a “professional” midwife isn’t deep enough educationally. The floor is too low, some of them are dangerous, yet some of them have done extensive self-guided education and are very competent and safe.
“To my great disappointment, many young women who want to become midwives seem to think it is too much bother, time or money to complete an actual midwifery curriculum and think it is enough to just apprentice themselves to someone for a minimal number of births, study to pass a few tests, and become a CPM that way.”
NARM doesn’t require a formal education beyond high school, so some CPMs are dangerous. There is no way for women to know which CPMs are safe and which ones are not. This certification path cannot be trusted by women or state legislators. Some states require the NARM exam plus education from an MEAC-accredited school. However, MEAC midwifery schools are so far outside the mainstream that the course credits don’t even transfer to the ACME midwifery schools that hospital midwives attend.
To protect women and babies, midwives attending homebirths should have the same education as hospital midwives, if not more. It was a mistake for states to ever codify the NARM+MEAC midwifery path into law, and it’s time to fix it, so the petition calls for the NARM certification to be phased out in the 28 states where it is currently recognized.
Malpractice Insurance - Malpractice insurance cuts the out-of-hospital mortality rate in half, without limiting access to homebirth providers. In any other area of healthcare, providers are required to carry malpractice insurance, either by state law or by the rules of their hospital employer. Midwives who exclusively work outside of hospitals, therefore, will only have to carry insurance if state law requires it. Guess how many states currently do. Two. Indiana and Florida are the only states that require midwives who deliver babies out-of-hospital to carry malpractice insurance. This is unacceptable, and families who have lost a baby or had a tragic outcome at a homebirth, such as the parents of Abel Andrews, will tell you firsthand that they had absolutely no recourse due to the fact that homebirth midwives don’t carry malpractice insurance.
Low-risk Scope - Numerous high-risk pregnancy and birth conditions should be risked-out of homebirth, including
- Preexisting maternal disease
- Significant disease arising during the pregnancy, such as diabetes mellitus
- Prior uterine surgery
- Non-cephalic presentation
- Multiple gestations
- Gestational age less than 37 weeks or greater than 41 weeks 6 days
- Ruptured membranes for more than 24 hours
- Meconium-stained fluid
If these birth scenarios were excluded from the homebirth midwives’ scope of practice in every state, homebirth would be so much safer. However, low-risk birth with a non-nurse midwife is still more dangerous than low-risk birth with a CNM. Currently in the United States,
“At least 30% of midwife-attended planned home births are not low risk and not within clinical criteria set by ACOG and AAP, and 65.7% of planned home births in the United States are attended by non-AMCB certified midwives, even though both AAP and ACOG state that only AMCB-certified midwives should attend home births.” (Grunebaum, et al)
The risk-out criteria in the petition is based on recommendations by the ACOG, the AAP, and criteria used in the Netherlands. It is unethical for any healthcare provider to attend these high-risk births outside a hospital because that would imply these births are safe, undermining a woman’s right to informed consent. It is equally unethical for state governments to allow midwives to charge money to attend these high-risk births out-of-hospital.
Reporting Outcomes to the Public - In Oregon, where homebirth outcomes are tracked correctly, including intrapartum deaths and outcomes of planned homebirths that resulted in hospital transfers, planned homebirth was found to be 8 times more deadly than hospital birth. Every state should track and report homebirth outcomes exactly as Oregon does. If homebirth is as safe as proponents claim, there should be no reason to hide this information.
Integrated System of Care - There are only 7 states that currently require homebirth midwives to have a written collaboration agreement with a physician. Requiring midwives to be integrated into the medical system benefits women by ensuring expert consultation and identification of risk factors and a smooth transfer of care, if needed.
Many men and women have already left comments on the petition stating they have lost babies to unsafe, unregulated midwives at homebirths. State regulations could go a long way toward improving the safety of homebirth. It's time for our voices to be heard. Join the women who are calling for safer homebirth, and