11/25/2014 EDIT: this was written a few years ago and since has been slightly modified from its original content. Another version of this article was published in SQUAT Spring 2014 magazine. There was also another article submitted by someone else that is a counter-argument supporting licensure requirement.
This is a question that has plagued the midwifery community for years. Those behind the “Big Push” want to legalize midwives, but with licensures behind them. Advocators such as Carla Hartley, among others, believe that while legalization of midwifery across the board is a must, requiring licensure will spell the end for mother’s rights in regards to their births. Those who advocate for licensure of midwives, which would make “lay” midwives and other direct entry midwives (DEM) who do not have a nationally (or state-wide) recognized license such as Certified Professional Midwife (CPM) illegal practitioners, argue that licensure sets “a standard” and “proves that the midwife underwent apprenticeship and training”. They also point out that with a license, midwives could be covered by insurance which would open up so many more families to homebirths. While this all may be true, I believe, along with those who advocate for legalization without forced licensure, that the downfalls outweigh the benefits. Here are some reasons why:
• Licensure puts restrictions on practice. It gives those who require the license the ability to put in place legal restrictions and subsequent ramifications if those restrictions are not complied. For example, a licensed CPM (in some states, not sure if it’s in all states), is not allowed to attend “high risk” births, such as those of breech or multiples, in a home setting. She is required to refer her client to a doctor for her prenatal care and delivery in a hospital setting. Which leads to our next big issue:
• Licensure limits women’s birth options. As seen in the previous example, when limitations are put on licenses, and thus midwives, it puts limitations on mothers. It limits who she can birth with, and where. It gives her an ultimatum. I could even go as far as to agree with Ina May Gaskin in her thought that such restrictions on midwives led to the rise in women seeking unassisted births—they’re having a breech and can’t have a midwife attend them for risk of legal ramifications for the midwife and they don’t want to birth in a hospital via required Cesarean? Maybe she’ll just birth at home on her own.
• Licensure, though it may set a “standard” and “proves that a midwife underwent training and an apprenticeship”, only sets a bar—the lowest setting on the wrung that must be met, skill and knowledge-wise, in order to pass an exam and receive a license. This exam does not, nor the license, tell what kind of midwife the license-holder is, nor the true extent of their knowledge, expertise, skill, and experience. It does not say how many years she apprenticed or studied, only that she did enough to meet the minimum requirements. In my search for the right midwifery training program for me, I have come across the following many a time: “This program only provides the basics and meets the minimum requirements set by MANA/NARM in order to pass the exam to receive CPM status.” I also have come across the following on sites such as that for the Michigan School of Traditional Midwifery: “Many students find that they are knowledgeable enough to take and pass the NARM CPM exam before they’ve even finished the 2-3 year course offered (but in order to receive a Diploma of Traditional Midwifery, they must finish the course in its entirety).” What does that tell you? That many programs out there will give you enough knowledge before even finishing to pass the licensure exam!
• Licensure also makes it harder for midwives who do not train through “MANA/NARM/MEAC accredited midwifery schools” to get licensed. I do not think that you should be required to attend only certain “approved” schools in order to become a midwife, or to become licensed.
• Licensure could allow midwives to carry drugs such as Oxygen and Pitocin, and numbing medication for sutures. But do we really want our midwives to be using these? I thought that seeking a midwife was to escape the medicalization of doctor-overseen births in hospitals? Not to mention, just having a license as a midwife (such as CPM) should not make it ok for a midwife to carry drugs such as those and others routinely used in hospital settings, especially when the proper use and administration of those drugs and management of labor after their administration may or may not have been covered in any amount of depth or detail in their “midwifery training program” (this is not the case, however, in some states such as Washington where midwives must take pharmaceutical training). If midwives want to carry drugs and be able to administer them, which I do not think that they should, but everyone is different and there may be mothers who want a home birth midwife capable of doing so, they should seek specialized training classes that certify in the use of those drugs, independently, not be allowed to carry them because an umbrella license allows them to without prior and specialized training.
• In regards to insurance coverage, this can be a tricky area. Once I saw that a family couldn’t justify taking the money out of their vacation fund to pay for a midwife! Others say, why pay a midwife when I have insurance who will pay for a doctor? They don’t really think, don’t feel so adamantly in their hearts, that a homebirth is what’s best for them and their baby. Or maybe they’re secretly harboring a fear of an out-of-hospital birth brought on by the Birth Fear that permeates our Westernized culture. Or, they’re being bullied by their partner. A bit drastic, but I know women who have sold their furniture and then some in order to pay a midwife so they could have a homebirth. I have yet to meet a midwife that does not do a “sliding scale” or a payment plan, etc. in order to help make it easier and more affordable for parents. I’ve even known a midwife to consider a partial barter of services. Midwives are midwives because they want to help women, not for the money. But the majority of midwives have made it their career, how they put money on their table and food in their children’s bellies. But many midwives out there do try to make it as easy for parents as possible, while still making at least a meager living, because they want to help. Also, not to mention that insurance companies dictate practice. Just look at doctors. Insurance companies set limitations on practice, liabilities, etc. In the words of Ina May, “Why should insurance companies continue to get away with limiting the skills that a health profession has always previously required of its members if they were to be considered fully trained?”
Personally, I do not think that mandatory licensing should be sought for midwives. I think it should be an option, but should not be required. For instance, in Utah midwives have the option of getting licensed or not, and either way they can practice legally. However, depending on if you’re licensed or not, you have certain quidelines you are supposed to legally follow. For instance, an unlicensed midwife could attend a breech birth at home, whereas a licensed midwife could not. A licensed midwife could carry and administer drugs such as Pitocin, whereas an unlicensed midwife could not. This type of practice is seen similarly in Oregon and Maine (in Maine CPMs can carry 5 different drugs for homebirth use, whereas non-CPMs cannot) and gives mothers and families a full spectrum of care-provider choices from unlicensed midwives all the way up through OBs in hospitals.
I think certification can be a good thing, but that still leaves out those who self-study with an apprenticeship, those who don’t attend an “accredited midwifery school”. (Certifications are received from completing school programs and may have different titles depending on the school. They show that the student finished and graduated from said program). People like to see papers. It’s true for anything. But papers do not prove the worth of the person who has them. It does not show their skill, their experience, or anything of the like. It is a piece of paper that makes people feel like that person is more “professional” or more “qualified” only because they have it, not because they know they are. And the more well-known the source of the certification, the more comfortable the clients may be, again regardless of seeing relevant proof of skill or knowledge. This should not be the case but is for many professions. (This carries over to doulas as well).
I believe that mandatory licensure of midwives in order to obtain legal status is not a good idea and should not be pursued. I think that it should be offered as an option, but not a requirement. I believe that families, especially mothers, should have all available options to choose from in regards to where and with whom she births, if anyone. They should be able to interview midwives of multiple backgrounds and training styles, regardless of certification or licensure or lack thereof, or what “style” of midwifery they were trained in. They should be allowed to make the best decision for themselves and their families, based off of presented evidence of the midwife’s background, personal skill, and training, regardless of what letters she has behind her name; what they are looking for regarding care (such as suturing or non-suturing, able to carry drugs or not, good relationship with local hospital, allowed to do breech at home, etc); past client testimonies and recommendations; and their own feelings regarding the care provider– even if those feelings change at the last minute– in their decision making as autonomous parents involved at the forefront of their care. I believe that the heart of midwifery training– academic training regardless of ‘schooling’ type coupled with hands-on apprenticeship with a senior midwife– must be preserved as the most ancient and authentic form of midwife training.
Some say that not making midwives get a nationally-recognized (or even state-recognized) license will allow un-trained “Wikipedia” midwives to run rampant calling themselves “midwife” and taking on clients. And this could very well be the case, but I doubt it. Because those “midwives” will be weeded out. By other midwives sure but mostly by mothers and families. I saw a case just of this instance based out of Michigan, I believe, where there are no requirements for licensure. A “midwife” who had no real, extensive training, nor apprenticeship, was going around calling herself a midwife, which she could legally, and was taking on clients. Many other “professional” midwives were outraged and scared. Which is rightfully so, but it was ultimately up to the parents to really look at who, and what, their midwife is. We can spread the word through our communities about such practitioners, if you would call them that, and we can try to warn families. But ultimately it is up to them to weed out the bad ones from the good. Which did happen in this instance.
Another large part of choosing a midwife (or doula, or any professional you will be working with intimately over an extended period of time) is how they “click” with you– their style, their beliefs, their personality, their “energy” even. This is oftentimes the critical turning point in a mother’s choice between care providers. If her choices are significantly whittled down due to legalities, her chances of “clicking” with the right care provider go down drastically. What if there is only one homebirth CNM in her area and all the other DEMs in the area are almost impossible, if not completely impossible, to track down (or, there just aren’t any in the first place) and she’s left deciding between a hospital birth, a homebirth with a CNM she perhaps doesn’t care for, or possibly she finds only one CPM who will attend her “under the radar”? This is usually the point when many women give up and give birth at a hospital, or they show interest in, or even undergo, an unassisted birth whether or not they came to that thinking it was best, or their only option. (Not only does this dampen a woman’ ability to choose between many care providers to find the right one for her, but it also drastically reduces the amount of women who can even be cared for by a midwife in the first place).
Mothers shouldn’t be forced to make such a huge and potentially impacting decision as to where and with whom they birth as dictated by legislation. And every woman should be allowed to make whatever decision she deems appropriate and best for her, her child, and her family, without fear of legal repercussions for herself, or for her midwife if she chooses to have one.