Even in the best of times, the U.S. faces a shortage of obstetricians and other medical professionals capable of delivering babies and providing prenatal and postnatal care. As America deals with the coronavirus pandemic, this shortage only stands to worsen. Meanwhile, pregnant women face a huge new incentive to consider giving birth outside of hospitals. Will U.S. authorities make it easier to embrace home births and midwives?
"I've had more interviews [with prospective clients] in the last week than I've had in maybe January and February combined," Ray Rachlin, founder of Philadelphia's Refuge Midwifery, tells me when we talk on March 20. "The demand for home birth has increased dramatically."
People have been wanting to avoid hospitals both out of fear of catching COVID-19 there and because they want to avoid new hospital restrictions, says Rachlin, who is a licenced midwife in New Jersey & President of Pennsylvania Association of Professional Midwives. Some hospital systems have been limiting or even banning visitors, including spouses, during deliveries.
"Over the past week, the Kentucky Birth Coalition has been flooded with contacts from people looking for midwives who attend home births," Mary Kathryn DeLodder, a Louisville-based regional liaison for the group, tells me in a March 23 email. "Kentucky has pockets that do not have any access to home birth providers, and many of the midwives are reaching capacity. We desperately need more midwives to meet the current demand."
"We've been contacted by people who are due anywhere from a few weeks from now to those due in the fall," DeLodder adds. "Folks are planning ahead in case the current restrictions persist."
Giving birth obviously can't be put on hold for the coronavirus. But as the outbreak intensifies, overstretched medical staff, limited doctor's office and clinic hours, and limited modes of transportation could prove logistical challenges for expecting families, even independent of any health risks.
In the face of the outbreak, the authorities have already been relaxing some protectionist rules around health care licensing and operations, such as those preventing doctors and nurses from working across state lines and those limiting the number of businesses allowed to make masks, ventilators, and hand sanitizer. Will we see similar momentum on home- and community-based health care for expecting moms and new babies?
For Years, The U.S. Has Needed More Birth Professionals
"There has been no growth in the number of obstetricians nationwide since 1980 despite increases in the number of women of childbearing age and the number of births," noted an October 2019 report from the California Health Care Foundation.
In a March 20 letter to the White House, American College of Nurse-Midwives CEO Sheri Sesay-Tuffour said her group is "gravely concerned that the COVID-19 pandemic will place further untenable stress on the current maternity care system and workforce." So it's asking the White House "for emergency measures to temporarily lift the restrictive licensure requirements that limit access to the midwifery workforce."
Midwives are not doulas, to be clear. The latter are more like birth counselors, providing information, emotional support, and physical assistance during pregnancy and childbirth but not direct medical care. Midwives are trained to care for women during labor and delivery, as well as provide prenatal and postpartum health care for women and newborns. Some are also permitted—depending on their license—to write prescriptions and provide general gynecological and "well woman" care.
Recent decades have seen a modest but measurable uptick in midwife-attended births, after they all but disappeared over the course of the 20th century.
"In 1900, almost all U.S. births occurred outside a hospital," according to analysis from the Centers for Disease Control and Prevention. This proportion dropped to 44 percent by 1940 and to just 1 percent by 1969, where it hovered throughout the 1970s and '80s. By 2004, out-of-hospital births accounted for just 0.87% of all recorded U.S. births.
But since then, non-hospital births have been making a small but steady comeback. According to a June 2019 paper published in the journal Birth, the number of home births increased 77 percent from 2004 to 2017 and the number of birth center deliveries went up by more than 50 percent. "In 2017, 1 of every 62 births in the US was an out-of-hospital birth," authors Marian F. MacDorman and Eugene Declercq found.
States Put Up Artificial Barriers
The increase in non-hospital births comes as some states have loosened midwifery rules. Back in 2004, Missouri midwives could still be charged as felons; the state's Supreme Court put an end to that in 2008. At the same time, some states have made it more difficult for midwives to practice.
Take Georgia. In 2015, the state said all midwives must have an advanced nursing degree and a Certified Nurse Midwife (CNM) license. Now, not only is it illegal to practice midwifery in Georgia without these credentials, it's also forbidden to even call oneself a midwife.
"What the statute and regulations do, and the way the Board of Nursing is enforcing it, is to say that no one can even say they're a professional midwife, or a licensed midwife," unless they have this specific license, says Caleb Trotter of the Pacific Legal Foundation (PLF).
PLF is suing on behalf of Deborah Ann Pulley, who works in midwifery advocacy and education. She "is not practicing as a midwife at the moment," notes the complaint, filed in the U.S. District Court for the Northern District of Georgia against the president of the Georgia Board of Nursing. Pulley practiced midwifery for many years, however, and is still licensed in Tennessee as a Certified Professional Midwife (CPM).
Trotter says the situation is like Georgia saying he can't call himself an attorney while in the Peach State, since he's licensed by California to practice law.
Like lawyers, midwives are regulated and licensed at the state level. In around 35 states, having a CPM license means you can legally practice as an independent midwife (though scope of practice allowed varies).
"You've got a vast majority of the states, the path to licensure is pretty straightforward," says Trotter. "It's only a minority of states, Georgia included—and they only did this about 5 years ago—that have taken the step to really limit who can get in and who can practice as a midwife."
Georgia is among a few states that refuse to recognize any midwifery as legal unless it's offered by a nurse-midwife. This also appears to be the case in Iowa, Nebraska, Nevada, North Carolina, and North Dakota, according to the Institute for Justice's analysis of occupational licensing across America.
Even in states with more flexible licensing policies, midwives are often artificially constrained by some state regulations.
These include rules preventing midwives licensed in one state from working in another, disallowing midwives from offering the full range of services they have been trained for, and requiring that they enter into unnecessary collaborative practice agreements with physicians. In only 18 states can even nurse-midwives diagnose and treat patients without such an agreement.
The American College of Nurse-Midwives (ACNM) supports "policies that allow Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) to practice to the full extent of their education, training, certification and experience" as well as "legislative and regulatory reforms that seek to eliminate unnecessary and costly supervision and collaborative agreement requirements."
In early March, an ACNM representative was among the health professionals who met with President Donald Trump and the COVID-19 task force for a briefing at the White House. In a statement about the meeting, ACNM Board Treasurer Cara Krulewitch urged officials "to the strain on our nation's health care workforce by allowing all health care providers to practice to the full scope of their training."
"Community birth has multiple factors that make it desirable right now to folks who may not have considered it before," points out DeLodder. "Even in normal circumstances, there are things such as hospital acquired infections. For many people, the idea of being in their own environment feels safer than being in a hospital, particularly in the midst of a pandemic."
What Makes a Midwife?
Midwives are not doulas, to be clear. The latter are more like birth counselors, providing information, emotional support, and physical aid during pregnancy and childbirth but not direct medical services. Midwives, meanwhile, are trained to care for women during labor and delivery, as well as provide prenatal and postpartum health care for women and newborns.
There are two main types of midwife licensing schemes in the U.S.: nurse-midwives and direct-entry midwives.
All 50 states allow certified nurse-midwives to practice. To get a Certified Nurse-Midwife (CNM) license, one must be a registered nurse with a master's degree or higher as well as complete a special midwifery educational program.
A few states also recognize a Certified Midwife (CM) license, which requires a master's-level or higher degree in a health-care field outside nursing, plus specialized midwifery training.
In February 2019, there were 102 CMs and 12,218 nurse-midwives in America, ACNM reports. Most midwife-attended births in the U.S. involve nurse-midwives, according to the National Center for Health Statistics. In 2017, births attended by nurse-midwives and CMs accounted for 9.1 percent of all U.S. babies born.
The vast majority of these still happened at a hospital. Only 3.2 percent of all the CM and nurse-midwife deliveries took place in stand-alone birth centers, and just 2.6 percent in people's homes.
This is in part a function of red tape that can keep hospital-based nurse-midwives from attending home births. "Restrictions such as oversight requirements in some states can make this very difficult," DeLodder tells me.
In any event, direct-entry midwives, who are trained and licensed independent of the nursing profession, are more likely to attend home births or birthing center deliveries.
The gold standard license for direct-entry midwives is the CPM license. Getting one ultimately requires passing an exam administered by the North American Registry of Midwives. CPMs needn't have a nursing license or a college degree. But the registry "requires that the clinical component of the educational process must be at least two years in duration and include a minimum of 55 births in three distinct categories," according to The American Academy of Midwives.
The CPM is the only midwifery license that requires training and experience in home-birth settings.
State of Limbo
"We passed a law in Kentucky in 2019 to license Certified Professional Midwives who attend home births," notes DeLodder. "While the license process isn't complete yet, it is very close. But there are still some states where CPMs are not licensed."
"Those states that do not yet recognize CPMs need to do so immediately," she suggests, adding that groups in those states are petitioning "to have licenses issued by executive order."
These states fall into two groups: those that explicitly say only nurse-midwives are allowed to practice, and those that only officially license nurse-midwives but don't directly prohibit practicing midwifery outside this.
Recognizing the CPM license could come with myriad advantages, including being able to draw from pools of CPMs in neighboring states. And for CPMs in these states, it could mean being able to actually accept private insurance payments, get reimbursed by Medicaid, and work more collaboratively with other health care providers.
"What we know from research is that better integration leads to better outcomes," says Rachlin of Refuge Midwifery, who also cites lack of insurance coverage for midwifery services as a major barrier for potential patients. (Just three percent of hospital births between 2004 and 2017 were self-paid, compared to a third of birth center deliveries and more than two-thirds of home births, researchers found.) Home birth "is a third of the cost of a hospital birth," says Rachlin. Yet it can cost patients much more in terms of out-of-pocket costs.
There are trade-offs to consider in states going from no regulations around home midwifery to offering the CPM license. If the CPM becomes the only non-criminalized path for non-nurse midwives, that could shut out a lot of experienced midwives, as well as stymie new entrants without the resources to be trained and licensed in this particular way.
Getting the state to grant you a direct-entry midwife license can be costly, ranging from $822 (in New York) to $2,600 in Wyoming, according to the Institue for Justice.
But there are ways around this. In Hawaii, which passed a licensing requirement for non-nurse midwives last year, the new rule exempts until 2023 any birth midwife who does not administer medicine and discloses their lack of licensing. A non-temporary exemption of that sort could help mitigate the negative impact on communities where informal midwifery is common, while giving pregnant patients across the board more care options and preventing non-licensed midwives who are honest about this fact from facing arrest.
Free the Midwives
So where can the government go from here?
First, states that say only nurse-midwives can legally practice should reconsider. Otherwise, they block out skilled midwives trained before these requirements were enacted; discourage new midwives who can't afford a master's degree; and put their pregnant residents at a disadvantage in terms of choice and—especially now—safety.
Second, states that neither forbid nor recognize non-nurse midwives should consider ways to bring these professionals into more alignment with the rest of the health care system (be it by offering a CPM licensure path themselves, permitting practice by people with CPM licenses from other states, or some novel way). But they should be careful that, in so doing, they don't ban merely calling oneself a midwife without a license (as in Georgia) or criminalize experienced midwives with alternative experience or certification.
Third, all states should have health regulators look at ways to stop artificially restraining midwives during this time of crisis. (Ideally, any rolled back regulations would be permanent, but there's no need to decide that now.) An easy place to start is with rules requiring telemedical appointments be treated differently than in-person visits.
"A lot of providers I've been talking to have been talking about [the need for] reimbursement for telemedicine," Rachlin tells me. With COVID-19 raging, "as much care as we can do outside the hospital and clinics is going to lead to better care."
Medicaid coverage is another area ripe for tweaks. "There are very few states where CPMs are covered by Medicaid," says DeLodder. Not only could changing that "increase access, but it also presents a savings to Medicaid as both home and birth center births are much less expensive than even the most straightforward hospital birth. Even better would be if CPMs were listed as Medicaid providers on the federal level."
Private insurers, which vary on coverage at present, could also "make a big impact and realize savings" by choosing to cover services from home birth providers, she says.
In longer-term moves, they could abolish "certificate of need" requirements for standalone birthing centers, which arbitrarily limit medical facilities to those that politicians and their cronies deem necessary for the community. This has left states like Kentucky without any freestanding birth centers.
"States could also provide emergency provisional licenses for birth centers and suspend certain requirements to allow facilities to open quickly," DeLodder points out.
The benefits of more midwifery could extend beyond the current crisis. Research suggests more midwife-assisted births could bring cost savings and better birthing outcomes, too.
Getting up to 20 percent of U.S. births to use midwife-led care by 2028 could save around $4 billion, according to a 2018 policy brief from the University of Minnesota School of Public Health. This would also reduce preterm births and episiotomies, the brief claims.
"Evidence shows that low-risk pregnant women who are cared for by midwives have similar outcomes to those cared for by physicians, but are less likely to experience unnecessary obstetric procedures," it goes on. "Additionally, physician shortages in obstetrics contribute to problems of limited access to care during pregnancy," which is something that more midwifery could mitigate.
"In Philadelphia, there are about six or seven practices, and we are all almost at capacity," Rachlin told me last week. "We're doing the best to work together so we can increase our capacity, and it's still not going to be enough."
One major barrier to expanding midwife care is hospital systems that don't want competition. "Hospitals in Kentucky have been vehemently opposed to increasing access to freestanding birth centers," says DeLodder. "However, as we are especially seeing now, we need access to all safe birthing options to free up hospital resources."
"There are risks and benefits to any [birth] setting," says Rachlin. "The risks of giving birth at home for one person may outweigh" the benefits, and vice versa. "It's important to help people be able to have the choice to give birth where they feel safe right now, and that may have changed recently because of the current pandemic."