Certified Nurse-Midwives can legally attend births in all 50 states (although not all can attend out-of-hospital births, due to various rules, regulations, legislation, or just plain politicking); Certified Professional Midwives can legally attend births in 26 states, with the remaining 24 states either outright making it illegal for them to attend births, or just not having statutes on the books one way or another (or they’re too vague). Some have noted that if non-nurse midwives (including certified as well as non-certified midwives) do not have legal protection, then they may be charged with practicing medicine (or midwifery) without a license, facing fines or even jail charges.
Many midwifery proponents advocate for changing the laws in the remaining states to make CPMs (or perhaps non-certified midwives as well) legal birth attendants, specifically, rather than relying on the gray area for protection. Not all do, though. Through the years, I’ve read numerous things on the subject, both for and against certification, with those against noting the potential downsides. I was made to think on this subject again with Gloria Lemay’s post. One of the things she notes is that legal midwives are often restricted from being truly autonomous, with the case in point of Canadian home-birth midwives being required to play by the rules dictated by doctors, including trying to jump-start labor at 41 weeks (by stripping the membranes), so these women could still qualify for a home birth, because otherwise they’d be induced at 42 weeks.
Molly at Citizens for Midwifery gives her thoughts, in this post, also linking to Gloria’s post, as well as a few others.
I favor certification for a few reasons — although I will admit that it is not without some reservations.
For one, it will standardize midwives, and I do think there are probably some midwives who need to be brought up to standards. How many there might be, I could not say, and without regulation, there is no way to know whether a midwife is qualified or not. Much like a driver’s license does not make you a good driver, but is merely an indication that you have passed a certain standard. In those states that do not have clear rules, midwives may be subject to prosecution anyway, and midwives would not have to become certified if they still wanted to operate outside the law. This may put them at a greater risk of prosecution, but it might not (if their position was uncertain or actually illegal before, then it wouldn’t seem to change much to continue to operate illegally); and it would certainly lower the risk of prosecution for midwives who did play by the rules. The downside, of course, is that “the rules” may be changed. I think this happened in Utah in the past year or two — midwives were first legalized, and then in a subsequent legislative session, a bill was at least under discussion, if not actually passed, to tighten the restrictions for births midwives could legally attend, including no VBACs, and no births where the mother had previously given birth to a child under a certain weight. So, if a mom had had a preterm birth at 30 weeks, regardless of the reason, or if she gave birth to two small twins, and then carried another child to term — despite the fact that this baby and this pregnancy were normal and non-eventful, a midwife would be legally unable to attend her birth. Or, the rules may not be evidence-based, or may be otherwise too restrictive. Also, Australian home-birthing has been undergoing some serious problems, with the legislature essentially writing a law making it illegal for midwives to attend home births (due to insurance regulations and restrictions). While it appears that that has been tabled, or at least is still under serious discussion and hopefully some renovation, midwives who attend home-births without insurance will be stripped of the legal title of midwife for the first “offense”, and then a subsequent “offense” will have them subject to a $30,000 fine and possibly jail time. However, in America, midwives may be subject to a fine and jail time in certain states now, even though they could be certified and legally practice in other states. So, I think on balance, it is better to at least have that as an option.
Certainly, government regulation can be a two-edged sword — giving with one hand while taking with the other. But it would be proof of meeting a standard, and we don’t have that now.
Without a standard and/or certification, a woman may hire someone who is truly not qualified to be a midwife, but she may not know that. If a woman calls herself a midwife, even though she has no training or very little training, mothers may assume that she is well-qualified, or has passed certain rigorous standard or testing, and/or has studied extensively. One midwife I read about said that she began attending births after some women found out that she had had a home birth (probably an unassisted birth), and asked her to attend their births. She did not mention any form of education about birth, except having given birth to her own children. While on one hand I can say, “As long as the mothers knew her skill/education level, then that’s fine”; on the other hand, I have to wonder/worry if other women may not know and just assume that she has the training of certified midwives. Often, women don’t know what to ask about, when interviewing a care provider — either just going with whoever is covered by their insurance, or assuming that all OBs are the same, or just are unfamiliar with the wide variation in practice styles of care providers (high vs. low rates of episiotomies, C-sections, etc.). The same may apply to midwives, as well, with women making assumptions based on a title.
Another factor on legality is that illegal midwives may be hesitant to transfer, fearing prosecution. This may end in higher morbidity or mortality for babies.
There is a lot that could be said on this topic. A lot of positives and negatives could be given about certification. I’m not dogmatic about it, and can be friends with people of differing opinions. What are some of your thoughts?
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