With advances in midwifery and a growing culture of self-determination, more women are choosing to give birth at home. Homebirth advocaters are asking how (or whether) law should address the threshold of life.
In 1900 most U.S. women had their babies at home. By 1940, according to the Centers for Disease Control (CDC), homebirthing had declined to 40% of deliveries, and by 1969 only 1% of U.S. births took place outside hospital settings. But especially over the last decade, more women have been coming back home to have their babies. Between 2004 and 2009, 31 states showed statistically significant increases in the rate of women choosing to give birth at home. And in eight states – Montana, Oregon, Vermont, Idaho, Washington, Utah, Wisconsin, and Pennsylvania — the home birth rate rose to 1.5% or higher.
According to the CDC, “In 2009, there were 29,650 home births in the United States (representing 0.72% of births), the highest level since data on this item began to be collected in 1989.”
As birth practices are changing, however, the health laws in many states have yet to catch up, a hardship and in some instances a criminal risk for women who choose home birth and the midwives who assist them.
The overwhelming majority of homebirths in the United States are planned homebirths and are attended by various trained birth professionals, most of whom use term “midwife” for themselves. Currently, 27 states have some form of legislation in place to legalize, license, or regulate the practitioners of homebirth midwifery. In 10 states, the practice of homebirth midwifery is outright prohibited by statute, judicial interpretation, or stricture of practice.
Kentucky is one of these states that prohibit homebirths, even as homebirth rates in Kentucky increased 26.7% between 2004 and 2009.
During the 2013 legislative session, a grassroots organization called the Kentucky Homebirth Coalition (KHBC) joined with similar organizations in states nationwide and found support to introduce a bill that would license direct-entry midwives under the Certified Professional Midwife (CPM) credential. (A direct-entry midwife is an independent practitioner educated “through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing.”)
The proposed bill would also create a Board of Midwifery in Kentucky to oversee the licensing of practicioners. The bill made its way to the state’s Health and Welfare Committee but did not receive a hearing during this legislative session.
Currently, because the state does not issue licenses to homebirth midwives, Kentucky – through omission — makes it illegal for direct-entry midwives to attend births in the homes of the families that choose them for their care. With each birth Kentucky midwives attend, they face the possibility of prosecution under various offenses, both misdemeanor and felony.
Despite this reality the number of Kentucky women choosing homebirth continues to grow, and the midwives who serve them continue to risk their livelihoods and wellbeing. Homebirth advocates believe that by creating a licensing system for midwives who have trained under the guidelines of the North American Registry of Midwives (NARM) and passed its exam, they will be creating an environment in which both the family choosing homebirth and the midwife attending that family will be protected. The midwife will have a license to practice in her state and a board of her peers will be available to her to evaluate her practice. A family will thus know that the CPM they have chosen is trained to practice and qualified under the NARM guidelines and that her work is also reviewed by her peers.
In this climate of uncertainty, what is motivating Kentucky women to choose homebirth? Do they feel safe in their choices? Cristin Stanley-Potter a mother of three residing in the mountains of southeastern Kentucky, explains her decision: “In all honesty, there isn’t much to choose from. The obstetricians in our area do not provide evidence-based care. There are few to choose from in general, which means that each practice has a large number of patients and little attention is given to each one. I chose to give birth at home because I wanted a more personal experience, and I wanted the best care possible for myself and my child. That is what I got.”
Jennifer Olliges, a mother and steering committee member for KHBC, says that the advancement and preservation of the homebirth option is crucial to rural women. “Maternity units continue to close in rural areas leaving rural women with fewer birth options and less access to adequate prenatal care,” says Olliges. “And the proportion of family physicians attending births continues to decline. Licensing direct-entry (non-nurse) midwives is one way to address the growing problem of rural women’s access to maternity care. Licensing midwives would help expand access to cost-effective and evidence-based maternity care. Midwifery care has been shown to reduce disparities in outcomes among vulnerable populations.”
Women feel limited in their choices with regards to birthing within our modern maternity care system. The mothers who choose homebirth believe in its safety. Like Cristin Stanley-Potter, many of these women have given birth before and, having experienced the standard of care in their local hospitals, they have made the decision to remain at home for subsequent uncomplicated pregnancies and births.
Another southeastern Kentucky mother of three, Jane Doe (who did not want her real name used for publication) talked about her experience with homebirth. She experienced one pregnancy and birth under the mainstream system and chose homebirth for both her succeeding deliveries. “I chose home birth because I believe it to be the safest option for me and my baby. I prefer the midwifery model of care and desired a different relationship with my care provider than what is offered in the obstetric field.” Jane Doe emphasized that the midwife she chose has a low rate of C-sections, hospital transfers, and interventions. “I desired a safe, comfortable environment for my birth,” she said, “and an attendant who was supportive of my needs and desires.”
Research studies back up her belief: a report published in the British Medical Journal (2005) found that not only is homebirth for low-risk women comparable to low-risk hospital births for the neonate, the risk to the mother is lessened due to lower rates of medical intervention.
Cristin Stanley-Potter described how her options for childbirthing are limited, adding that access even to those limited options can be difficult: “I live in the countryside, about half of an hour away from any town, or even any store. I would consider my home somewhat remote.” By choosing home birth, Cristin accepted certain risks. What if complications had arisen?
Cristin says, “Being that I live the distance that I do from any town, I also live that far from any hospital – and farther from any hospital that would be able to provide me the care I would need in the event of an emergency. I realized that had I truly needed medical care in the event of a serious complication, I may or may not have made it to the hospital in time enough for intervention. Having given birth in a hospital two times prior to my homebirth, I came to the conclusion that the unnecessary interventions I would face there were far more risky for myself and my baby than the small chance that I would need to transfer. I chose a very knowledgeable midwife who I trusted completely. I felt safe. It never crossed my mind that something negative might happen during my birth.”
Olliges shared a statistic from the Kentucky Institute of Medicine that brings this issue into new light – “55 of Kentucky’s 120 counties, most of them being rural, are designated Health Professional Shortage Areas.” Furthermore, the American College of Obstetrics and Gynecology projects that a future shortage of obstetricians (the number of ObGyns declining by 25% by 2030) will disproportionally affect rural, semi-rural, and medically disenfranchised areas. These physician shortages have significant implications for rural Kentucky families.
Those who believe licensing to be a move forward in Kentucky’s maternity care hope that the added protection of licensing will encourage more people to consider midwifery a viable career. In such an environment, the homebirth midwife could better serve women of all income levels, including those utilizing Medicaid. Women who lack transportation could be better served by midwives and receive proper pre-natal care. And as more midwives work in conjunction with obstetricians in regions like Eastern Kentucky, pregnant women, both high-risk and low-risk, would more likely keep all scheduled prenatal appointments. The World Health Organization agrees, “Midwives are the most cost-effective and appropriate primary caregivers for all childbearing women in all instances and in all settings. Home is the most appropriate birth setting for most childbearing women.” (World Health Organization Report on Health Promotion and Birth, 1986)
Of the thirteen states that currently have active bills active concerning midwifery licensure, eight have rural populations above the national average – Alabama, Georgia, South Dakota, Iowa, Indiana, Michigan, and North Carolina. Several of the states have been working toward the goal of licensing midwives for a number of years. Despite the apparent benefits that licensing would have for families who choose homebirth and the midwives who serve them, some homebirth advocates do not favor licensing. A few states have chosen to forgo licensing in favor of laws that state that midwifery is not the practice of medicine and therefore falls outside of medical regulations. Maine, the most rural state in the nation according to the last census, is one of these states. “In 1978 the Attorney General issued an opinion that asserted that pregnancy and childbirth are part of normal, healthy human functioning and are therefore not covered by the Maine Medical Practice Act. As a result midwifery is not considered the practice of medicine in Maine and a medical license is not required to attend women in pregnancy and birth.” (Maine Association of Certified Professional Midwives)
To varying degrees the advocates who do not favor licensure agree that midwifery should be thought of as a traditional craft; they argue that it is in no way a practice of medicine nor is there need for regulation by a board. Those who take such a position usually hold that, instead, laws are needed that make midwifery legal and uphold a mother’s right to choose any caregiver she determines is best suited for her needs. They believe the only way to preserve the autonomy of a midwife’s practice, reduce the limitations on the women she can serve, and safeguard every woman’s right to give birth where and with whom she chooses, is to protect midwifery as a community tradition. The definitional issues, the beliefs underlying them and the legal ramifications are clearly complex.
Women who choose homebirth often emphasize that they are simply seeking reliable, loving, respectful, and evidence-based care. For some women a midwife’s credentials and/or licensing matter a great deal; others look more to the midwife’s personal experiences and her personality in deciding on the family’s birth attendant. But all women and men working within the growing homebirth movement believe in the safety of homebirth as well as a mother’s right to choose where and with whom she will give birth.
Women who choose homebirth are overwhelmingly proactive in their approach to maternity care and they also are typically self-educating, studying their options and the safety of their choices. For Jane Doe, the risks that she anticipated from homebirthing weren’t about her baby’s or her own physical safety, but about the judgment of others who look upon mainstream childbearing as safer.
“Comparing the rates of transfer, C-section, and intervention between my midwife and the medical practitioners in my area revealed a dramatically lower health risk associated with midwifery care. My risks were more about social stigma and how my choice would affect not only me but my husband and his relationships with work colleagues and his business.” Jane Doe adds, “These concerns have proven to be mostly unfounded. The advantage of choosing a safe birth heavily outweighs any chance of dealing with uneducated criticism.”
With homebirths constituing about 1% of all births nationwide, many homebirthing women fear and/or face criticism of their choice from those who regard their decision as risky. This social stigma can often put mothers in awkward situations within their communities as they try to explain their decision. For some, this social discomfort is all the more a reason to create further protection for the choice of homebirthing.
Most homebirthing mothers see this option as a right: to be the one in charge of their healthcare and the care their growing family receives. It means preserving childbirth as a normal rite of passage in their lives as women and establishing a sacred space for birth, protected by the family. Cristin Stanley-Potter. says, “My homebirth was my most positive experience as a mother. Nothing can compare with the care I was given, the trust that was placed in my body and the understanding my care provider had of this normal process. That cannot be found in a hospital or with an obstetrician, at least not here. It was perfect. My children woke the next morning to a new baby brother, it was as if the time between that in which I was still pregnant and the moment in which he was born was unbroken. Our lives went on as if he had always been there.”
Jane Doe uses the same reverent tone when speaking of the moments when her third child, a daughter, was born, “Bringing my daughter into this world with the love and support of my birth team, in the comfort of my home, is a moment I expected to be proud of but rather, it felt so unbelievably normal (and glorious). Feeling my daughter’s head as she left my body is a moment I’ve committed to memory. The entire experience felt so perfect, just, and average…birth as it is meant to be.”
This legislative session in Kentucky closed with no change in the law books regarding homebirth midwifery due to the volume of considerations and time constraints of this session, yet home birth advocates are hopeful. Jennifer Olliges writes on the KHBC website, “It is not just that we share the belief in physiological birth and a woman’s ability to make her own choices about where and with whom to have her baby. It is more basic than that. I think I can say with some certainty that we share a sense of self determination. The belief that every person has the right to make the life they want for themselves and their children, starting at birth. This gives me confidence that we will shape our state how we see fit, including ensuring that mothers in our state have access to midwifery care.”
As more rural women nationwide gain access to homebirth midwifery, it should be recognized that as much as the rural life is based in autonomy, it is based also in community. While there are great changes occurring in the lifestyles, demographics, and economies of rural communities, our traditions remain. The marriage between traditional midwifery and our new knowledge and techniques surrounding childbirth is making birthing at home safer than ever before. The ancient art of birthing babies takes a strong mother and the support of her village, also. We are seeing that the mystery of life and the options how we will experience that mystery made manifest are bound to basic questions of individual rights.
Kelli B. Haywood, MAT, LCCE, is a mountain woman born and raised, homemaking mother to three daughters, and a Lamaze Certified Childbirth Educator, doula, and women’s and children’s health advocate. She lives in southeastern Kentucky with her husband and three daughters. See her weblog about childbirth and prenatal care: Birth True.