Benjamin Franklin once wrote, “Nothing is certain except death and taxes.” However, prior to both death or taxes, one must first be born. And throughout human history birthing women have been attended by midwives. Today, this remains true in most countries except for the United States where the majority of women are attended by obstetricians.
That said, a wide array of midwives do exist in the US. Nurse midwives practice mostly in hospitals and birthing centers under the oversight of doctors.
But an array of non-nurse midwives, also known as lay, direct-entry or community midwives, practice under laws that vary from state to state. These midwives specialize in the care of mothers and newborns, with the understanding that much of what a nursing degree entails is not relevant to their practices.
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Because I had a mother who birthed my two younger sisters at home, I was familiar with midwifery when I became pregnant with my first child in 1993. The same two midwives attended the home births of my first two sons in Columbus while my last three were attended by the same midwife in Northeast Ohio.
In 1996, while I was pregnant with my second son, community midwifery in Ohio was suddenly jeopardized. In an advanced-practice nursing bill, the State Medical Board tried to have the State Nursing Board take on the oversight of community midwives.
The State Medical Board mislead the nursing bill’s sponsors when telling them that community midwifery remained only in Ohio’s Amish communities. An early draft of the nursing bill would have made community midwifery, outside of a religious community, a felony for the midwife and a misdemeanor for the birthing mother.
The bill’s language was so aggressive most community midwives were afraid to speak out for fear their names would be collected and they’d be charged with a crime should the bill pass. Instead, home-birth mothers became the face of community midwifery at the Ohio Legislature.
As the founding director of Ohio Friends of Midwives, I informed the sponsors of the nursing bill that the Amish are not unique when it comes to home births with midwives. Furthermore, the majority of midwives attending Amish mothers are not Amish themselves.
The criminalizing language was stripped from the nursing bill and a legislative study council, of which I was a member, was created to help state legislators better understand how community midwives practice in the state and what, if any, regulations should be considered.
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The study council met monthly for 12 months, heard testimony from some in the medical community opposed to community midwives and testimony in support of community midwives from sociologists and nationally recognized community midwives, including Ina May Gaskin, who for many years taught several birthing techniques to obstetrical students.
But it was the testimony from families who had birthed children with community midwives that perhaps had the most impact on the study council.
At the July meeting supporters filled a large hearing room and the hallways at the Statehouse. The turnout was higher than at any previous public testimony event for any other issue in the state’s history. A second session of testimony was scheduled and equally well attended.
In the end, the Direct-Entry Midwifery Study Council decided to leave community midwifery legal and unregulated in Ohio. The Ohio Department of Health created a registration process for community midwives to sign verifications of pregnancy and live births, including birth certificates, and the ODH supplies newborn screening tests to community midwives.
Also, under the Ohio Administrative Code, community midwives are allowed to practice at exempt birthing centers, of which there are currently six operating throughout the state.
In the 25 years since the study council submitted its final report, Ohio’s community midwives have continued to attend women throughout the state, serving families from all backgrounds, educations and incomes, in rural, urban and suburban communities.
And they’ve done so with remarkable outcomes.
One reason for this is that mothers with high-risk pregnancies, the definition of which is debatable, are referred out to obstetricians. But secondly, the Midwifery Model of Care, which provides a wholistic approach with pregnant women, consistently results in better outcomes.
While doctors and hospitals have an important role in maternity care, the current system in America needs improvement. The statistics for infant and maternal mortality and morbidity in the U.S. are unacceptably grim. In 2018, the U.S. ranked 32nd among developed countries for infant mortality, while preventable maternal deaths rose nearly 200% from 1993 to 2014.
When the statistics for Black mothers and babies are removed from the U.S. data, however, the numbers noticeably improve, revealing a complex problem that was the subject of an entire issue of The New York Times Magazine in 2018.
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Here in Ohio two recent bills propose to radically change the way community midwifery is practiced in the state. Sponsors of both bills claim their legislation will address the unacceptable outcomes of Black mothers and infants by expanding midwifery care.
Of the two bills, House Bill 496 seems to have the most traction. As written it requires the licensure of community midwives with the goal of providing care in birthing centers, and possibly hospitals, where Medicaid is accepted. But it would also criminalize the practices of all non-licensed community midwives.
On June 9 of this year, while listening to the local NPR program “The Sound of Ideas,” I was stunned to hear two supporters of HB 496 claim that Ohio doesn’t have what they called “granny midwives” (a condescendingly quaint and grossly inaccurate term). I called the show and informed the host that Ohio has, in fact, more than 100 community midwives practicing everywhere in the state.
In response to my call, one of the guests, who had just claimed community midwives don’t exist in Ohio, stated that these very real midwives can’t bill insurance, so Ohioans pay for them entirely out of pocket. This is also not true. I’ve given birth to five children at home in Ohio and all were covered by whatever private medical insurance I had at the time, including my last birth in 2012.
If the practices of community midwives, who are currently legally recognized in the state of Ohio, become criminalized, many women in Ohio will continue to birth at home, particularly in Plain communities, but without the benefit of a midwife. As a result, maternal and infant mortality and morbidity will increase.
One way to bring the Midwifery Model of Care to mothers on Medicaid without criminalizing community midwifery is to enlist the assistance of what are known as doulas. As pointed out in the New York Times Magazine issue on this topic, when doulas, who provide preventative and supportive care to mothers, work alongside obstetricians, outcomes improve.
But the simplest solution would be to make licensure optional for Ohio’s community midwives as other states, such as Minnesota, have done.
There is no reason for Ohio’s legislature to endanger one population in an effort to help another population. For as long as Ohio has been a state, community midwives have been attending birthing women with great success. Their practices present no problems that need solved by criminalizing their profession.
This was first published in the Akron Beacon Journal on Sunday, October 2, 2022.