This second class of poorly trained midwives attend the majority of American home births. And yet they are legal in only 28 states; in the rest of the country, many practice outside the law.
They used to be called “lay midwives” or “direct entry midwives,” in recognition of their lack of formal medical schooling. That didn’t sound very impressive. In a brilliant marketing ploy, they created a credential — the C.P.M. — and awarded it to themselves. Many receive their education through correspondence courses and their training through apprenticeships with another C.P.M., observing several dozen births and presiding at fewer. How woefully inadequate is this education? In 2012 the requirements were updated to require proof of a high school diploma.
They seem to believe they don’t need more training because they are “experts in normal birth.” As I often say, that makes as much sense as a meteorologist being an expert in sunny weather. Anyone from a taxi driver to a 12-year-old sibling can handle (and has handled) an uncomplicated birth. The only reason to have a trained attendant is to prevent, diagnose and manage complications, the very things that C.P.M.s never have to learn to do.
Another difference between the United States and Canada is that in Canada home birth is governed by strict eligibility requirements that exclude women at high risk of complications (no twins or breech births, for example). In contrast, the Midwives Alliance of North America, the organization that represents C.P.M.s, eschews such standards. Each C.P.M. is apparently charged with deciding for herself what is safe.
The organization’s statement of ethics in fact rejects “traditional codes of ethics that present a list of rules to be followed.” Instead, “a midwife must develop a moral compass to guide practice in diverse situations that arise from the uniqueness of pregnancy and birth as well as the relationship between midwives and birthing women,” it says. “This approach affirms the mystery and potential for transformation present in every experience.”
The American Congress of Obstetricians and Gynecologists has published 163 clinical bulletins to establish parameters for safe and effective practice for all obstetricians. The American College of Nurse Midwives has published 14 such bulletins. I know of none issued by the Midwives Alliance of North America.
In the absence of safety standards, C.P.M.s have been known to attend births of women with serious medical conditions at home. In Oregon, midwives are protesting the state Medicaid program’s decision to stop covering high-risk home birth, and in Arizona, where midwives cannot legally attend certain kinds of high-risk births, they have been lobbying to have the law changed.
Finally, home birth in Canada is integrated into the obstetric system. Nearly 25 percent of women (including 45 percent of first-time mothers) are transferred to a hospital during labor if there is even a hint that a life-threatening complication might develop. In contrast, I have known C.P.M.s to boast of transfer rates of 10 percent or lower, either because they don’t recognize impending complications or they believe they can manage them at home.
One reason transfers are routine in Canada is that Canadian midwives have hospital privileges, meaning they can continue to care for their patients in the hospital. If American C.P.M.s transfer a patient, they lose control of her.
These midwives might also put off transferring a patient because, if they are operating illegally and a baby is injured or dies, they could face criminal charges.
Personally, I would always opt for a hospital birth. But many women want to give birth at home, and Canada shows us that it is possible for them to do so safely. What can we do to make that true in the United States as well?
It is very hard to crack down on midwives operating illegally. Instead, we should focus on informing pregnant women about the risks and the fact that C.P.M.s would not even qualify as midwives in other developed countries. If women knew, most would not hire them.
But we need to do more. We must abolish the C.P.M. and demand that all American midwives meet international standards; keep women at increased risk of complications from giving birth at home; insist on transfer to a hospital at the first hint of potential problems; and require that midwives have hospital privileges.
Medicine is not regulated by the federal government, so these changes would need to be made on the state level. Home birth midwives will lobby against them, fiercely, while the women who have suffered from home births gone wrong are often ashamed and less willing to speak up. But as long as we allow poorly trained laypeople with watered down credentials to perform home births, we are risking the health of mothers, and the lives of babies.