Law & the Midwife

Midwives offer care for women through pregnancy and delivery.

The word "midwife" means "with woman," and the traditional role of a midwife is to be present with a woman during her pregnancy, labor and delivery. Modern midwives have various levels of training and experience, and the role of midwives sometimes conflicts with the role of obstetricians during labor. Laws governing different types of midwifery practice reflect the debate about the relative roles of midwives and obstetricians and the most appropriate type of care for normal pregnancies.

Significance

Laws governing the practice of midwifery have a direct impact on what choices are available to pregnant women regarding their care. In places where midwives are more strictly regulated or licensing requirements are unclear, women are more likely to be attended by obstetricians.

Types

In the United States, there are three types of midwives. The first is a certified nurse midwife or CNM, who is certified through the American College of Nurse Midwives. Different states have different requirements for the licensing program, but all require CNMs to have training in nursing as well as midwifery. Most CNMs work in hospitals or birthing centers. They also can attend home births, but they rarely do because their practice must be under the supervision of a doctor, and many doctors are unwilling to supervise home births.

The second type of midwife is a certified professional midwife or CPM. CPMs are trained only in midwifery, not in nursing. They can be trained through apprenticeship and self-study or formal schooling. They are certified through the North American Registry of Midwives. They usually attend births in birthing centers and homes. Different states have different laws regulating those with CPM licenses, and some states do not recognize the CPM license.

Direct-entry midwives may or may not be certified, and they attend births at homes. They are trained through apprenticeship, experience, self-study and sometimes formal school as well. Some of them practice illegally, depending on the laws of their states.

Geography

The practice of direct-entry midwifery, regardless of whether the midwife holds a license such as a CPM, is prohibited in the District of Columbia and nine states, as of 2010: Alabama, Illinois, Indiana, Iowa, Kentucky, Maryland, North Carolina, Pennsylvania and South Dakota. Direct-entry midwives are legal by statute in Georgia and Hawaii, but because no licensing for direct-entry midwives is recognized in those states, they cannot legally practice. Direct-entry midwives are legally recognized, licensed and regulated in 26 states, as of 2010: Alaska, Arkansas, Arizona, California, Colorado, Delaware, Florida, Idaho, Louisiana, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin and Wyoming. All of those states recognize the CPM license, and some require additional certification or registration. Direct-entry midwives can practice legally by judicial interpretation in nine states, as of 2010: Kansas, Maine, Massachusetts, Michigan, Mississippi, Missouri, Nevada, North Dakota and Oklahoma. Direct-entry midwives are neither regulated nor prohibited in Connecticut, Nebraska, Ohio and West Virginia.

All states allow certified nurse midwives to practice in any setting under the supervision of a physician.

Considerations

In states where midwives are not licensed or recognized, women who wish to give birth out of a hospital setting often do so without the back-up of obstetricians who have participated in their prenatal care. In the case of complications during birth, both the women and their midwives face additional complications of potential legal problems when they transfer to hospitals for further care. In places where the practice of midwifery is recognized and licensed, women are able to give birth outside of hospital settings with the back-up of obstetricians who practice alongside midwives in case of complications during labor.

Expert Insight

According to Citizens for Midwifery, the World Health Organization states that "a woman should give birth in a place where feels is safe, and at the most peripheral level at which appropriate care is feasible and safe. For a low-risk pregnant woman, this can be at home, at a small maternity clinic or birth center, in town or perhaps at the maternity unit of a larger hospital...It must be a place where all the attention and care are focused on her needs a safety, as close to home and her own culture as possible." However, the American College of Gynecology opposes home births, stating that "monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies." Laws that affect the practice of midwifery reflect this ongoing debate.

References

• Faqs.org: Midwifery in the United States
• Midwifery Alliance of North America: Direct-Entry Midwifery State-by-State Legal Status
• Citizens for Midwifery: Planned Home Birth is Safe for Most Mothers and Babies
• American College of Gynecology: Statement on Home Births