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Few women in labor, awaiting the birth of a baby, spare a moment to think of their state legislature. But they might be surprised to learn that, increasingly, state legislatures across the United States are thinking of them.
Following the passage in April of a reform bill legalizing the supervision of home births by certified professional midwives (CPMs) in Wisconsin, similar reform efforts are now underway in no fewer than nine states.
Alabama, North Carolina, Idaho, South Dakota, Illinois, Kentucky, Georgia, Missouri, and Indiana all await legislative debates that could lead to the licensure of certified professional midwives, says Ida Darragh, chairman of the board of the North American Registry of Midwives (NARM), the national organization that tests and registers CPMs.
Legalization and licensure of CPM practices in all these states would represent a massive legislative victory for advocates of traditional home birth.
It would also be a startling rebuke to the many physicians who have long maintained that such practices are unsafe, despite growing statistical evidence that suggests CPM-supervised home births are as safe – sometimes safer – than hospital births.
Well-organized opposition within medical lobbying groups makes such a one-sided result unlikely within the next two years, Ms. Darragh says. But, when asked if the flurry of activity in the nation’s statehouses is indicative of a national trend in support traditional childbirth methods, she adds: “We certainly hope so.”
As with many health issues, the debate about CPMs may seem arcane to non-experts. The debate is a minefield of acronyms, and home births account for just 1 to 3 percent of all births in an average year, with similar percentages in each state.
Yet the debate casts in sharp relief a philosophical tug-of-war over the nature of childbirth that powerfully affects how expectant mothers approach the ordeal of birth.
Elsewhere as in Wisconsin, this tug-of-war pits midwives and physicians who support “natural childbirth” outside the hospital setting and with minimal intervention against the many physicians and nurses who view medical birthing techniques as safer.
When Wisconsin’s reform takes force in May 2007, Wisconsin will become the 23rd state to institutionalize a way for expectant mothers to reject a medical birthing culture entrenched since the 1950s.
Activist midwives say the Wisconsin reform adds bulk to a growing body of circumstantial evidence that America’s popular view of childbirth is in flux, with parents adopting new perspectives on labor and the role of modern medicine in it. CPMs describe labor and birth as “natural” events rather than medical emergencies necessitating medical intervention.
“I think it is a trend,” says Katherine Prown, legislative chair of the Wisconsin Guild of Midwives. “We have seen Minnesota, Utah, Virginia and now Wisconsin all pass laws since 1999. There is a lot of momentum behind these bills.”
Traditional midwifery is struggling to reemerge from the obscurity in which it has languished since passage of Medical Practice Acts (MPAs) by all 50 states, in the 1950s. These acts criminalized the “practice of medicine” by unqualified individuals. They need not have impacted traditional midwifery, but they did in 49 states because only Mississippi offered an exemption for midwives, Ms. Darragh says.
Yet whatever the movement’s momentum, there is also powerful opposition. The American College of Obstetricians and Gynecologists (ACOG), a well-funded proponent of childbirth in the hospital setting, opposed the Wisconsin reform, publishing a position paper stating that CPM-supervised home birth “cannot be considered safe”.
ACOG also urged state officials to take “immediate aggressive action” against “unsafe birth practices”.
Such action was seen earlier this year in Indiana, where state prosecutors earlier this year charged Jennifer Williams, a CPM, with practicing medicine without a license. Ms. Williams, who says she helped 1,500 women give birth safely before she faced any charges, pled guilty. She has since filed a lawsuit against the state attorney general, asking an Indiana circuit court to distinguish between midwifery and “the practice of medicine.” Ms. Williams is also part of the group campaigning for legalization and licensure of CPM practices in Indiana.
The divergence in approach between Wisconsin’s legalizers and Indiana’s prosecutors shows the wide variety of options available to legislators and regulators. States have essentially three options: to legalize, license and regulate the work of CPMs as Wisconsin and 22 other states now do, to prosecute CPMs as Indiana and some others have done, or to turn a blind eye as Mississippi does.
Democratic pressure on statehouses throughout the country could one day yield a consensus, either in CPMs favor or against them. In the meanwhile, those embroiled in the debate are confronted with a growing body of scientific research.
One study frequently cited by CPMs was published last year in the British Medical Journal, an academic publication, by Kenneth Johnson, senior epidemiologist for the surveillance and risk assessment division of Canada’s Center for Chronic Disease Prevention, and Betty Anne-Daviss, a project manager at the Ottawa-based International Federation of Gynecology and Obstetrics.
The study reviewed records of all CPM-supervised home births in North America in the year 2000 and led Dr. Johnson to conclude that “planned home birth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intra-partum and neonatal mortality to that of low-risk hospital births in the United States.”
Asked to provide any statistical evidence contradicting such studies, for the sake of this story, ACOG sent none but e-mailed two policy statements further explaining the organization’s position on the certification of midwives.
Links:
American College of Obstetricians and Gynecologists
http://www.acog.org
North American Registry of Midwives
http://www.narm.org
Wisconsin Guild of Midwives
http://www.wisconsinguildofmidwives.org
Study published in British Medical Journal (see third-to-last paragraph of story) bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom
British Medical Journal
bmj.bmjjournals.com
Comments
Thank you for such a balanced article.
I find it very telling that ACOG was unable to present any statistical evidence to refute the BMJ study or other medical literature supporting the safety of home birth. I also find it somewhat interesting that, in its most recent position statements on midwifery, ACOG has backed away from its earlier stance of outright opposition to home birth. It’s a subtle shift, but basically their position now is that if a family does choose home birth, the only appropriate provider is a Certified Nurse Midwife (CNM) working under physician supervision.
This indicates to me that their real gripe with recent legislation legalizing Certified Professional Midwives (CPMs) isn’t opposition to home birth itself, but opposition to the independent practice of midwifery. Of course, what all of ACOG’s position statements on these issues fail to mention is that only about 1% of CNMs nationwide provide out-of-hospital services. Why? Because the OB-GYNs they work under refuse to allow them to.
So it’s somewhat disingenuous of ACOG to whine about CPMs attending home births when a) they themselves acknowledge (see WI ACOG’s position statement on midwifery legislation) that some families will always choose home birth and b) they’re responsible for preventing CNMs from meeting the demand for out-of-hospital maternity care. The only conclusion to reach from these contradictory positions is that ACOG wants to force families to give birth at home without trained attendants, which of course they would deny. Yet they continue to adopt policies on midwifery legislation that, were they enacted, would result in an increase in unattended home births.
Thankfully, legislators in a growing number of states are recognizing the self-serving motivations behind ACOG’s opposition to CPM licensure and are choosing to adopt policies that protect public health and safety rather than those that protect ACOG’s professional interests.
I am a new mother, just having given birth to my son a week ago. We chose a home birth because the midwifery model of care spoke to us and provided us with exactly what we were looking for in our pre-natal, labor and post-natal care. We had the absolute pleasure of working with two of the most wonderful midwives, who took excellent care of our family. I strongly believe that every woman and family ought to be given the choice of how they would like their child to enter this world.
You can always tell when a group like ACOG has no facts/statistics to support their claims - all they spread is fear and doubt. Where they should be focusing their attention is on the many problems with the current medicial model of care. Just today yet another article was published regarding our pathetic track record of care in the USA. See http://query.nytimes.com/gst/fullpage.html?sec=health&res=990CE3DF1338F935A15754C0A963958260
and
http://www.cnn.com/2006/HEALTH/parenting/05/08/mothers.index/
I would like to thank you for your balanced coverage on this issue.
I am a mother of four all of which were born at home in the water with a lay midwife.
We are expecting our fifth any day (EDD was 8/30) and I broke my leg on 8/20. We will still have a home water birth even with the surgery (plate, 8 screws) and cast (cast cover made for swimming).
While in the hospital I was more scared that I would be induced or taken than I was about my leg or how to take care of four kids 7 and under by myself.
Home birth is not for everyone. Hospital birth is not for everyone. I wish my state made home birth legal, however--why should we be punsihed for imformed choices?
Thank you for covering this issue in a reasonable light!