Black Market Midwifery: Lack of Regulation Compromises the Safety of Women Who are Committed to Giving Birth Outside the Hospital Setting

Christina Perez-Tineo
Associate Editor
Loyola University Chicago School of Law, JD 2020

Across the United States more and more women are choosing to give birth outside of hospitals. Currently, in Illinois, Certified Professional Midwives are not licensed to provide home birth services. However, over the last decade, advocates in Illinois have urged lawmakers to reconsider this restriction. The most recent attempt in 2017 was unsuccessful once again. While opponents argue that individuals with this level of training should not be providing care to women during delivery, the choice for women who are committed to home birth is not between home and the hospital. It is between home and an illegal or unassisted delivery.

The Current Licensing Landscape for Midwives

Midwives provide support for women with uncomplicated pregnancies during pregnancy, delivery, and for some time after the baby is born. Midwives can generally be organized into three groups: certified nurse-midwives (NMs), certified professional midwives (CPMs), and community midwives. The training and certification requirements also vary by state, which contributes to the confusion around what midwives can and should do.

Certified nurse-midwives are registered nurses who are trained as nurses before completing supplemental training in midwifery. In Illinois, nurse-midwives must complete a master’s in nursing as part of their midwifery training. Nurse-midwives are certified by the American College of Nurse Midwives to provide birthing services in hospitals, birthing centers, clinics, and homes.

Non-nurse midwives can receive certification as CPMs through the North American Registry of Midwives. CPMs must meet general education requirements, sit for a written exam, and meet clinical experience requirements gained through apprenticeship with a nurse midwife or certified nurse midwife. There is some overlap between the scope of NMs and CPMs, but CPMs are more likely to receive specialized training and attend home births if their state allows.

Community midwives (also called “lay” or “direct-entry” midwives) are not certified or regulated in a uniform way. They usually receive informal training through apprenticeships.

Home Birth in Illinois

Most states have a framework for regulating midwives. Illinois is not one of those states, and the lack of recognition and regulatory structure is a barrier for individuals who would like to practice midwifery in Illinois. Further limiting options for pregnant women, doctors and certified nurse midwives primarily work in hospitals, and while they are the only licensed home birth practitioners, they provide home birth services in less than 10 of the 102 counties in Illinois. All but two of these counties are in the Chicago metropolitan area.

As women increasingly choose to give birth at home for any number of religious, philosophical, or cultural reasons, they have no way of ensuring their midwife has met any sort of state regulatory standard and are sometimes driven to the services of uncredentialed midwives to give birth illegally or on their own. Establishing Credentials for certified midwives, rather than continuing to keep them operating outside the health care system can make home birth safer in Illinois.

In 2017, the Home Birth Safety Act was introduced in the Illinois General Assembly but did not make it out of the senate committee. This was the most recent attempt to recognize certified professional midwives in Illinois but certainly not the first. The bill would have established standards for the qualification, education, training, and experience required for those seeking a license as a certified professional midwife who could attend home births. The bill also included requirements to work collaboratively with hospital-based and privileged health care professionals and agreed upon consulting, transfer, and transport protocols.

Incorporating Midwives into the Health Care System

 The American College of Obstetrics and Gynecology (ACOG) has provided some restrained support for midwifery and CPMs. In a committee opinion released in 2017 and reaffirmed this year, the committee stated that, while they believe hospitals and accredited birth centers are the safest settings for birth, they believe each woman has the right to make a medically informed decision about delivery. They further call for additional studies to assess the efficacy of planned home birth, which up to this point have been inconsistent and unreliable.

The ACOG committee opinion also outlines two major factors necessary for safer home birth: appropriate risk criteria and availability of safe and timely transfer of the laboring patient. As ACOG points out, intrapartum and neonatal deaths are more common than expected among “low-risk” women giving birth outside of hospitals. It therefore emphasizes the need for strict and uniform criteria to guide selection of appropriate candidates for planned home birth.

The second factor the ACOG highlights in their committee opinion is a robust regulatory structure that incorporates midwives into the health care system. They note that when women give birth at home with a midwife, rather than in hospitals, factors that contribute to comparable outcomes include uniform, highly educated and trained certified midwives, and established arrangements with hospitals in case transfer to a hospital is necessary.

Currently, Illinois’ regulatory environment fulfills neither of these criteria, but women in Illinois continue to seek uncredentialed midwives to give birth at home and midwives continue to practice in the shadows to meet this demand. Whether or not women should be giving birth at home is not the issue. The issue is whether Illinois will regulate this industry in the interest of safety, because it will continue to operate regardless.

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