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Why Licensing is a Dandy Idea

A couple of days ago, Birth a Miracle Services posted “Why state licensure is not the answer for midwifery,” a discussion (of sorts) arguing the point that is, well, in the title of the post. 

They (Naomi Kilbreth and Haley Grant) say: 

 “The assumption is that if a certified or lay midwife is required to be licensed by the state that they will all of a sudden offer better midwifery care, and that they will have better communication with medical care providers, and that they will be held accountable if they practice negligently.” 

I counter that with: 

If state and (hopefully) national licensing becomes standardized and enacted, midwifery as we know it could change dramatically –for the better. Homebirth non-nurse midwifery could, in my opinion, become a far more accepted profession. 

The acknowledgement that the safety of moms and babies is much more important than politics and dogma would speak volumes about homebirth non-nurse midwives’ motivations and goals. 

BaMS continues: 

“Licensure of midwives limits them to offer services only to the women AMA paid politicians consider good candidates, which rules out VBAC’s at home, and breech and twin births, even if the midwives had decades of experience in these situations.” 

I’m not sure where the idea came from that politicians decide who the good candidates are for a homebirth or not, but from what I have seen around the country (and I admit I am not an expert on midwifery law in the US), if anyone anti-homebirth is asked to define the scope of practice, it is doctors, not “AMA paid politicians.” But, I’ve seen midwives and consumers also be asked for input. And it doesn’t take an Act of Congress to know what the limitations on homebirth midwives would be; even midwives have a pretty clear understanding of what’s safe to –and not to- do at home. 

If midwives were all licensed, it is my hope that midwives would all operate within the standards of care that were (if I had my dream world realized!) developed by Licensed Midwives (and in conjunction with a couple of Certified Nurse Midwives) and acknowledged (not necessarily accepted) by obstetricians so women outside the standards (or who move outside the standards) are able to, gracefully and politely, slip into the obstetric system with the midwife giving a report that is believed and where women are treated with respect. And, once the glitch in the health of the baby or woman has passed, the obstetrician releases the woman back into the skilled and knowledgeable hands of the midwife. 

California Licensed Midwives were integral in the definition of our Standards of Care, including the, arguably, most important section in them, on page eight (emphasis mine): 

“Section V, Risk Factors Identified During the Initial Interview or Arising During the Course of Care, Part B, Client’s Right to Self-Determination: In recognition of the client’s right to refuse that recommendation as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal. If the licensed midwife appropriately documents the informed refusal in the client’s medical records, the licensed midwife may continue to provide midwifery care to the client consistent with evidenced-based care as identified in this document and the scientific literature.”  

I remember working on these Standards way back in 2004/2005, how even midwives who never interacted because of personality or practice clashes, worked tirelessly to create these Standards. We understood they would be created with or without our say and input. We also knew they would be binding for years ahead (and they have been). While what we here in San Diego presented to the creation committee was somewhat more liberal than what ended up in the law, we fought hard for the “Client’s Right to Self-Determination.” It was, for many (if not most) of us a non-negotiable part of what we would agree to. I don’t know if any other state has this right to self-determination, but I would beg anyone working on midwifery laws in their state to insist this be a required part of the wording of their law. 

What the right to self-determination does is give the woman the control over her own birth. If she is pregnant with twins and wants a homebirth, if her midwife gives her the proper education regarding risks and benefits… true Informed Consent… the woman can decide to continue with the homebirth, either with that midwife or another more experienced midwife, despite what the Standards of Care require. The same with breech births and VBACs. (Although our law does not overtly limit the right to VBAC at home [page seven].) 

BaMS makes the oddest claims about why a midwife, without a legal reason to stay within the parameters of safe midwifery, would “keep moms and babies safe.” 

“If a midwife has her license revoked, she can still practice midwifery if she finds clients willing to accept the risk. In comparison, a non-licensed midwife accused of malpractice will have her face plastered in every anti-homebirth website and may be jailed for “practicing medicine without a license”, even though midwifery is not medicine. Either way, licensed or not, a careprovider offering bad care will get a bad rep. Anyone wanting to keep their job is going to practice in a way that will keep their job, aka keep moms and babies safe.” 

A bad reputation? A bad reputation and the threat of being made a spectacle in the press is supposed to be incentive to keep moms and babies safe? That sure hasn’t worked so far! 

There are concessions one makes with rules and regulations. Midwifery isn’t a profession that believes any mother is a good candidate for a homebirth. Midwifery is an acknowledgement that homebirth is a safe location for low-risk women. And, hard as it is to admit sometimes, we all are pretty clear about what is low-risk and what is not. And when we aren’t able to decipher whether someone is low-risk or not, there are studies and even the experiences of others to turn to. It is in that research where we find that vaginal twins and breeches aren’t always the lowest of risk for either a homebirth or even a vaginal birth. Certainly medicine believes VBACs don’t qualify as low-risk, either, but many midwives and post-cesarean women themselves, disagree. I, myself, would fight for a woman’s right to VBAC at home. (Do I believe a VBAC to be low-risk? A low-enough-risk to deliver at home, yes.) 

But, doesn’t the line have to be drawn somewhere? Aren’t there always going to be women just over (or under) the (risk/legal) line that will be left out of the homebirth they’re wanting? Is it the midwife’s job to please everyone or is it her job to oversee the safest pregnancy, labor, birth and postpartum for mom and baby? One of the hardest things a midwife has to do is to say “No” to a woman begging to have a homebirth. 

BaMS continues: 

“What about the bad birth stories? Yes, what about those stories? They happen far more often in the hospital, but those docs aren’t being publicized as negligent. Much of the war against midwives is by a group of people who think they must decide for women that their home is not safe to give birth in.” 

Instead of discussing the “bad birth stories,” BaMS deflects to the too-oft-repeated “It happens in the hospital, too!” This, in my opinion, is not a valid argument. What of the homebirths-gone-wrong? What about the midwives who were negligent and where babies were injured or died? Just because things happen in hospitals doesn’t mean we ignore what’s happening in our own communities. 

BaMS suggests: 

“Instead, home birth advocates should spend their time informing the public on how to have a safe home birth, how to find a good midwife, and teach responsible decision making.” 

It astounds me that this is where they suggest the energies be focused. Not on insisting midwives have more education and training. Not on looking for a way to elevate homebirth midwifery in the eyes of the masses… and the government they so strongly abhor. The government isn’t going away. Licensing isn’t going away. 

Women don’t need to be taught how to pick the best midwife if all the midwives have the same education and training. Women don’t need to be taught how to have a safe homebirth if the midwife they’re hiring understands and is able to provide the safe homebirth a woman expects and deserves. And midwifery advocates should be teaching responsible decision- making!?! Women hire midwives to help them make those decisions. Right or wrong, women depend on the midwife (or other care provider) to know what she’s doing and to guide them towards the healthiest and safest birth, whether that’s in the home or the hospital. 

After Business of Being Born came out, I started seeing more mainstream clients choosing homebirth. My most recent doula and monitrice clients saw BoBB and wanted someone to help guide them through the process, stopping just short of a homebirth. Interestingly, even though they’d been affected by BoBB, they still were reading mainstream books like “What to Expect.” 

In my experience, mainstream clients don’t ask the doctor what school they went to, what training they had or even how many babies they’ve had die. They don’t ask how the grievance process works because all of those things are a given. Their education is standardized, even as each school teaches a little differently. It is understood that each doctor has a level of competence before they ever see their first private client. 

It should be that way with midwives, too. Women shouldn’t have to learn to ask where a homebirth non-nurse midwife went to school, how she apprenticed or if she’s lost any babies. She also shouldn’t be baffled by the grievance process, confused at every turn with the midwife-in-question’s friends and colleagues in charge of “disciplining” her. Licensing can take care of all these areas. 

I’m going to close this part for now. There’s more in that blog post I want to address, but this has gotten long enough already. More soon.

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Reader Comments (11)

Thank You!! I hear the "Trust Birth" rhetoric all over the web and it really bothers me. I am a student midwife and I am also a practicing licensed massage therapist. Massage therapy, like midwifery, is regulated differently in each state. When I graduated from massage school, I took a national certification exam. The exam tests for an entry level understanding of the art and science of massage therapy. This exam is not recognized in all states, like the CPM, but is accepted as the standard in quite a few. When I was approaching graduation I heard many students bemoaning the difficulty of the exam. I was nervous. If it was as hard as they said it was, would I pass? Luckily, on test day, I found myself more than adequately prepared. After I sat for the exam I thought to myself, "If someone couldn't pass that exam, I wouldn't want them to give me a massage because they wouldn't really know what they were doing on a physiological level!"

Now that I am studying to become a CPM, I feel the same way. There needs to be a standard that shows a midwife has achieved the entry level knowledge and skills required in order to be a safe midwife. I agree with you that licensing will protect families from dangerous midwives, and that the licensing should be written in a way to protect the families rights to decide, with informed consent, whether or not they choose to take a risk with a home birth.

When I hear so many anti-licensing midwives going on and on with their paranoid conspiracy theories about licensing, it makes me shudder to think of the incompetent and dangerous midwives who are enjoying the benefits of their arguments. There are too many direct entry midwives out there who have not and will not take their education seriously. The general public deserves to be protected from care providers like that.

It also drives me nuts how the anti-license camp is always going on about how midwifery is by definition non medical. Midwives are CARE PROVIDERS. Even if they deal in low risk pregnancy, these women are looking to their care provider for guidance the same way they would look to other care providers. I agree that the relationship between a midwife and her clients is more of a partnership than that of an OB and their clients, but I also feel that someone who is being entrusted by women to care for them and their babies should be held accountable by someone. Not all women will come to a midwife ready to be 100% responsible for every bit of research and direction needed to make her decisions. She looks to the midwife for guidance and trusts that she will receive the advice of a professional who has met at least a certain level of preparation before handing out that advice and care.

As a massage therapist, I am held accountable and it is good for my profession. In states where there is no licensing for massage therapist, there are all kinds of problems.In states where we are licensed, we don't see those problems. I happen to live in the ONLY state that considers massage therapy a limited branch of the medical field. In all other states with licensing, it is considered a professional occupation. But even in those states, practitioners are held responsible by a licensing board. That accountability raises the level of care that clients receive. I believe home birth midwifery would benefit from the same kind of accountability.

August 7, 2011 | Unregistered CommenterBethany

I completely and totally agree with everything you've said. I wish more people thought like you did.

August 7, 2011 | Unregistered CommenterLaura

Your post is spot-on. I read the OP and found it interesting that (as usual) most of the reasons for not licensing is about the midwife's freedom to practice and has little to do with the safety of the clients and their babies. The point that it is up to the mom to decide when she is in trouble and needs to transfer is ridiculous in my mind. Isn't that a big part of the reason for *having* a midwife to begin with? So that when you're emotional, lost in labor and not sure if something is normal there is an expert there to say "Yes, this is fine" or to discuss options with if there is a problem. I mean, if a midwife isn't willing to take responsibility for the advice she gives why is she practicing? I do think this is taken to the extreme sometimes- blaming midwives for bad outcomes- but they do need to recognize their own culpability when things go wrong and have their work reviewed by others to determine if they are practicing unsafely. As women should also be able to know about investigations into practices.

I recently witnessed some very dangerous advice being given to a mom in my area by a DEM. It made me sick, yet there is little/nothing I can do about this other than not to refer moms to her and tell people I know will keep it confidential that this woman might not be the best person to trust for care. I also know about others attending births for mothers who are high risk and would be better served in a medical setting since DEMs don't carry life-saving meds... but there is nothing I can do.

Thank you for this post!

Licensing is a two-edged sword for the consumer. I feel that non-nurse midwifery is the wild, wild west of healthcare and the fact that many practioners are unlicensed or illegal may help make that evident to unwary mothers.

Licensing can give the appearance of the state's endorsement of the education and skills of a midwife. It is only appropriate if the midwife is actually competent and therefore CPM status cannot be the sole qualification for becoming state licensed. CPM status on its own is inadequate and the qualifications of a licensed midwife must be much more stringent.

Licensing is also protective of the midwife -- let's not forget that. Doctors are rarely, rarely charged with criminal manslaughter, and being a licensed medical professional is the reason for that.

August 7, 2011 | Unregistered CommenterJane

Oh for the love of little baby animals.

I do not want to have to cross-examine a woman who I am considering having as a birth attendant. I do not want to investigate her resume, or research the quality of the program from which she graduated. I don't want to have a UC with an audience.

I feel like I should be able to engage someone to attend my labor and birth who has demonstrated the competence to keep my baby and I safe. The requirement that the each expectant mother has to operate as a de facto licensing board on her own behalf drives women AWAY from homebirth. It drove ME away from it.

August 7, 2011 | Unregistered CommenterKate

"What the right to self-determination does is give the woman the control over her own birth. If she is pregnant with twins and wants a homebirth, if her midwife gives her the proper education regarding risks and benefits… true Informed Consent… the woman can decide to continue with the homebirth, either with that midwife or another more experienced midwife, despite what the Standards of Care require. The same with breech births and VBACs."

I disagree vehemently with this. Not all women are suitable homebirth candidates, and CANNOT BE ALLOWED TO ENDANGER THEIR BABIES OR THEMSELVES. It is all about what precisely is the sphere of practice of a midwife, NOT what the woman wants. When I was in the UK the standards were very clear: ONLY a woman who was having her second, third, or fourth birth, and who had never had any medical or obstetric complication in any of her previous pregnancies or in the current one, was eligible for homebirth [there were also requirements for the place in which she intended to give birth; very basic requirements, but the home had to be suitable too]. The midwife was required by law to keep adequate records, which had to be submitted to the official body which supervised midwives, at intervals, was required to attend periodic refresher courses, and of course her licensure was dependent on having trained in an approved educational institution and having passed the necessary examinations. Thus the woman giving birth could be assured that her midwife was competent. What a great many silly women do not seem to understand, when they search for a "midwife" who undertakes the highest of high-risk cases blithely, is that all this is for the protection of the mother and baby. To paraphrase the Rolling Stones, she doesn't get what she wants, she gets what she needs.

August 7, 2011 | Unregistered CommenterAntigonos

I also would love to see licensing required and standardized across state lines. You know what you're getting when you hire a doctor, a dentist, a nurse midwife, even a realtor. Homebirth midwives should be the same.

Licensing is a hot issue in my state right now, especially following a recent horrific and preventable homebirth death at the hands of some unlicensed midwives. Since licenses aren't required in Oregon, sadly, these women may walk away unscathed after treating the poor mother so badly and killing her baby with their arrogant incompetence. Women should be able to choose a homebirth SAFELY, but right now there's so little transparency it's hard to tell who is good and who is scary.

I have blogrolled you at my new blog which is designed to help women have a forum for telling and hearing the truth about the local homebirth scene, Oregon Homebirth Reality Check. Thanks for your writing!

August 8, 2011 | Unregistered CommenterAnonoregonian

Why have two different licensing classes at all? The CNM already exists. Why not stick with that? If you don't, then you get "the skilled and knowledgeable hands of the certified nurse midwife, or the less skilled and less knowledgeable hands of the certified professional midwife." Why would anyone choose a care provider who is *by definition* less knowledgeable?

August 8, 2011 | Unregistered CommenterAlison Cummins

Yes, this is exactly why I would not be open to CPM assisted home birth anymore. And I had two of them. In retrospect, my affection for my midwife blinded me to some serious issues in care. And I never would have identified it as such without having a truly skilled CNM caring for me now. I would have just continued to think that my birth experience challenges were my fault, and had nothing to do with some poor judgment calls that were made.

Women don't just deserve midwives: they have the right to know that their midwives really DO pass muster, having passed the toughest standards and holding the highest qualifications. Otherwise it really is just a bunch of excuses for how substandard care is OK as long as it's "empowering," and what do you know but "babies die in hospitals too." Pay no attention to the relative risk behind the curtain there if there are substandard attendants with the public having no assurance that the provider they choose truly is a safe choice.

Please continue to write on this, Barb. Please. The lack of self policing in home birth circles needs to stop.

August 8, 2011 | Unregistered CommenterJH

Antigonos: I *knew* you'd speak up! And I'm really glad you did. Your viewpoint is surely more popular with legislators and OBs.

I do want to speak an aside to you, too, that whatever issues you have with my personal life, feel free to email me and discuss them. Flinging my past and present about as if they were epithets was rather rude, to say the least. My marital history, nor my sexual orientation, nor my spouse's gender has one iota of a thing to do with my midwifery, monitrice or doula practice. If I offend you because of those realities, you know you don't have to read here anymore. But, I am human, with real human issues and changes going on.

I believe the changes only serve to make me more compassionate and a much better care provider.

August 8, 2011 | Registered CommenterNavelgazing Midwife

Nicely put.

Standardized licensure is only one necessary step of what I see as a multi-pronged approach to protecting the public from incompetent providers. The first is, of course, ensuring a midwife is appropriately educated and trained--an issue I know you've addressed in the past. Licensing the incompetent won't make them any more competent.

Then, of course, you need to establish standards for practice and disciplinary procedures with teeth. As you've pointed out, the homebirth community in a given area is likely to be small and insular, which leads to abuse when the disciplining body is made up entirely of members of that community.

Another part is transparency. Right now in California (for example), you can get a fair amount of information on your physician, including lawsuits filed against her and actions against her license, even if those actions do not result in revocation. You can get some of that information on CNMs as well, through the CA Board of Registered Nurses. California licenses non-nurse midwives, but the only information you can get on them is whether or not they hold a current CA license. And there are generally no lawsuits because, of course, they are not required to carry malpractice insurance.

August 8, 2011 | Unregistered CommenterSquillo

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