Legal barriers cause difficulty for midwives

Two weeks ago, over 130 birth activists in New York lobbied in Albany for the passage of the Midwifery Modernization Act. What is this Act all about? As you may be aware, New York midwives (like midwives in 35 other states) are currently required to have a written practice agreement with a physician in order to practice. It is difficult for many midwives to find physicians who will sign one of these agreements. Many doctors believe that if they sign one, they will become liable for all of a midwife’s patients. Others are restricted by their malpractice insurance providers from collaborating with midwives. If a physician who has signed one of these agreements stops working for any reason, his or her partner midwives are no longer legally permitted to work. The Midwifery Modernization Act would remove this problematic requirement.

The written practice agreement requirement is unnecessary because licensed midwives (like all health care providers) have always been required to provide referrals to other appropriate medical professionals when a client’s needs fall outside of a midwife’s scope of practice. Midwives are bound by professional standards and ethical obligations, and will continue to follow these in the absence of written practice agreements. Fourteen states—AK, AZ, CT, DC, ID, IA, ME, MN, NH, NM, OR, RI, WA, and WY—as well as many countries in Europe with better birth outcomes than the U.S. do not have written practice agreement requirements. Their experiences demonstrate that this is not needed.

Agreements with doctors are only one of an array of legal barriers that impede midwifery care. Only half of U.S. states recognize certified professional midwives (CPMs)—experienced providers who are certified by the North American Registry of Midwives (NARM) and attend most home births in the U.S. In the other 25 states, CPMs can be prosecuted for practicing medicine without a license. This prevents many women who want to enjoy the benefits of midwifery care from accessing it.

A third—perhaps the largest—hurdle is medical insurance. While hospital-based care provided by certified nurse midwives (CNMs) is covered by many insurance companies, few cover care provided by certified professional or other direct-entry midwives, or care provided at home. Medicare and Medicaid—which provide insurance to more than one in five Americans—only reimburse CNMs 65% of their fees (although thanks to the new health care bill, this will rise to 100% starting next year). Medicaid refuses to cover the fees of certified professional midwives in all but nine states, forcing many low-income women to obtain their care from hospital-based providers.

If you are a woman with a healthy pregnancy, getting your care from a midwife rather than an ob/gyn reduces your chances of delivering by cesarean section, having a low birth weight baby, and losing your baby. You (or your health insurer) will also probably pay less for your care—in some cases, more than two thirds less. Given that midwives provide better care for less money, it’s a no-brainer that we should institute legal structures that encourage them in their work. What needs to happen in the state you live in to improve midwives’ eligibility for insurance reimbursement and overall autonomy?