Funding for To The Contrary provided by: This week on To The Contrary: Community birth has been a par of our history in this country.

My family was born at home at the hands of a midwife.

We can save a lot of like millions of dollars by hiring a midwife and increasing the number of midwives in the communities.

Hello, I'm Bonnie Erbé.

Welcome to To The Contrary, a weekly discussion of news and social trends from diverse perspectives.

This week, home birth, which is becoming much more popular in the US.

Meanwhile, it's also fueling a national debate over safety and regulation.

More women are choosing to give birth at home as mistrust in hospitals, the desir for fewer medical interventions and shortages of maternity care proliferate.

At the same time, many states restrict or do not license the midwives who primarily attend these births, creating a legal gray area.

Joining me this week are Tigist Ejeta, president of the National Association of Certified Professional Midwives, and Tina Sherman, the National Director fo Maternal Justice at Moms Rising.

So starting with you, Ms.

Ejeta.

Why are more people having home births than ever before?

Most people are choosing home birth because they are looking for a space that is safe for them, that they feel they are seen and supported.

And the reasons are deeply cultural and they are personal.

And we also have systemic barriers that are kind of encouraging them, but also forcing them to choose out of hospital births.

And we have growing families, growing number of families who are choosing because we have higher intervention—higher increase and intervention in hospital births and impersonal care that is not in alignment with either their personal beliefs or their cultural choices or their personal autonomy.

And those are some of the reasons why they are choosing home births.

I want to add some historical context.

Births were actually, prior to the 20th century, mostly at home.

Historically, community midwives have filled the gaps that have existed, especially in rural communities across the country.

It is only with the 20th century and policies that led to the medicalization, and that increasingly pushed families of their homes into the hospitals.

And while on one hand this was fueled by the Sheppard-Towner Maternity and Infancy Act, and on one hand, whil this absolutely helped to expand public health, it also did a huge disservice to so many familie who were choosing to give birth in their communities safel with their community midwives.

And again, this wasn't just that long ago.

So our maternal crisis that we're facing right now is newer in our history.

And we can put some of those ties back, directly back to the Sheppard-Towner Act.

Are there any regulations that require midwives to be licensed by the medica community in some way, the way doctors or nurse or most medical personnel are?

Yes there are.

And each what makes United States unique is that eac state has their own regulations and requirements for midwives to practice, and that is specifically true for certified professional midwives.

We have the nurse midwives who are licensed and are free to practice in all 50 states in the United States, but that is not true for certified professional midwives.

And all states have their own restrictions with regard to access to medication, emergency service and their freedom to collaborate with hospitals and physicians obstetricians and other provider So midwives have to navigate through this, the state requirements.

And currently we have 39 states that, including D.C., that midwives can—certified professional midwives specifically can practice in home and freestanding birth centers.

The rest of the states are not licensing certified professional midwives and they have huge gap in access the families have huge gap in access to midwifery care, specifically for home birth and freestanding birth centers.

Because certified professional midwives are the only credentialed midwives that are specifically trained to practice in the community setting.

Now what—you say there are regulations, but is there anything that stops someone who does not have a licens from being a midwife at a birth?

Yes, because there are legal requirements and legal penalties that are put on midwives.

If they are practicing, they are considered illegal in that specific state, if they are not— if the state is not licensing midwive and that puts families at risk, and that puts also the midwives at risk if they are found to be practicing midwifery illegally in that state.

So there are legal issues related to that.

I'm just—I'm not sur of the answer to this question.

So and I didn't ask you to be prepared for it.

But are there— is there any percentag of births performed by midwives or watched over by midwives that go bad, where the women need to be taken to the hospital for emergency care?

Well, I think one of the things that's important to think abou when we talk about the legality and where midwives are able and legal to practice, is that we first and foremost recognize that midwives have gone through training and are certified through their national certification board.

And then we have indigenous traditional midwives who are then trained in their community.

And so when we talk about legal access, we really need to ensure that we are not restricting or criminalizing midwives because families are— birth is happening wherever families decide they want to choose to give birth, and we want to ensure that there is safe access to all of the options in which they choose to give birth.

So we really want to be carefu to not restrict or criminalize midwives in any setting where they're going— we want to be able to provide, you know, the legal capacity as well as have the collaboration, if there are transfers that need to happen from the home to the hospital or on the birth center to the hospital.

Emergencies happen in birth every day.

That is just the reality of giving birth, you know, in humanity, right?

Emergencies happen every day.

And so it's importan that the collaboration is there between all of the prenatal health providers and the hospital systems.

Now, also, I, you know, deaths of mothers and labor used to be.

I don't know how common but more common than it is today certainly.

Today, do we know— does that still exist?

And what happens if it happens in a birth with a licensed midwife?

That's actually not entirely true.

Today, unfortunately, we are facing a maternal mortality crisis in this country.

The United States is actually—while we spend the most on maternity care, we have one of the highest maternal mortality rates in the developed world, to b clear, in the developed world.

And so and these— many of these statistics are coming from the very hospitals, which is why some families are choosing to opt out of the hospital.

And one of the things that we don't want to do is not have a legal framework and a medical framework for those families to pursue the birthing options that they choose.

If we're comparing the cost o having a baby in the community setting versus in a hospital setting, we have lots and lots and lots of evidence pointing that having your your baby with a community midwife, with a midwife costs less than having a baby in a hospital, and we can save a lot of like millions of dollars by hiring a midwife and increasing the number of midwives in the community so that families can have access to midwifery care.

And we have enough evidence to support that compare to having a baby in a hospital.

So if it is as safe or around as safe as it is having a baby delivered by an obstetrician, then why aren't— and is less expensive— why aren't people at the state level trying to get it approved in every state and trying to get it more commonly used?

Well, I think there's a couple of things than that.

I don't think it's that blanketed of a statement that it's that safe.

It's—in first and foremost, midwives and OBs and all health care providers are practicing within their scope of care.

And that's critically important.

Out of hospital midwives specialize in normal birth.

And so ensuring that families that have complications or a high risk birth have access to that high risk care is critically, critically important.

And so when we talk about safety, we also need to talk about midwives and all health care providers practicing within their scope of care.

We really want to focus on evidence based practices.

We want to talk about respect for the patient and what they value, their bodily autonomy.

We want to ensure that hospitals offer, again that safe transfer because with emergencies that do come up, we do want to have the safe transfers and so that there is collaboration.

This isn't about competition.

It's about serving families.

And we want to make sure that there is that collaboration.

So when we talk about what why aren't, you know, every stat sort of jumping on board?

I think there's a lot of education that needs to happen.

And I think we're both attempting to do that, appreciate this opportunity to do that here.

There's a lot of education.

There's a lot of miseducation that has happened as well.

And we also can't tear apart the history and the destruction of pulling community midwives and community birth into medicalization that is intertwined in this system as well.

So really dismantling all o that is really, really critical, as we continue these conversations with state lawmakers and policymakers.

And Ms.

Sherman in how many states is it legal to use a midwife versus a, I don't know, a nurse or an obstetrician?

I believe that there's 32, but I believe my partner here can share a little bit more.

Your thoughts, Ms.

Ejeta.

We have 39 states currently licensing certified professional midwives, and we are working on the advocacy part for the rest of the states.

And it takes a lot— It takes a lot done.

Just the community asking for like having a licensed midwife in their state because it's more complicated than just a simple advocacy.

There is a lot that the community and the midwives and the people involved in the legislation.

We have a lot of education that we need to do, and safety is a tricky thing to think about.

You can't— it's, in my opinion, safety and autonomy are not in opposition and we have a CPM.

We have a standard of practice that includes, like the foundational commitment to transparent communication, informed decision making that we do with our clients.

And there is shared responsibility through that.

And we— midwives do like a holistic risk assessment so that they know who can stay in their care and who has to risk out of their care.

And also in this process we are respecting the client's autonomy.

So how we can balance that safety so that clients can get their their choice of birth and in the choice of their birth setting would be like doing the solo risk assessment, which we always do, so that we can know who's staying in our care, who is out of— who is risking out.

Washington Stat is, for example, a good example of like a good maternal outcome because they have established transfer protocols, because they have— they are better in integrating midwives somehow in their system so that they can communicat with their like obstetricians.

And there is option for collaborative care, and there is option for them to have access to medication.

And this all ensures safety when you have a system that is built to support midwives in the community and you don't have to, and the families, the pregnant women don't have to restart like their prenatal care and they don't— the history could be shared and collaborative care could be there, when we have like a good system that integrates midwives.

Now when there are problems in birt and you said there are 39 states that approve midwives In those 11 states that do not, what kinds of problems have arisen in the past, I suppose, with midwives, if theyve allowed them in the past, or what kinds of problems occur in any state that allows midwife births, so that women who are considering this as an option know what the dangers are?

Again, carefully when I give folks an opportunity to sort of think through when we talk about safety and risk.

You know, my family was born at home at the hands of a midwife.

I have been hearing for many, many decades now about my dad's first memory of a birth of my cousin where he, I was told to go down to the school house where the teacher of the school hous was also the community midwife.

And I thought this was just a story about my cousin.

No, it actually turns out she caught all nine babies in my family on my paternal side.

And again, this is my dad.

Community birth has been a par of our history in this country.

And I want to be clear, also, as a black woman community birth at the hands of black midwives has been a part of our nation in forever.

So when we talk about risk and— I talked abou risk and how to ensure safety, we have to start with no criminalizing midwives, ensuring that midwives have— are practicing.

and all, again all, health care providers are practicing within their scope of car or referring out their patients to their collaborative health care OBs and partners when necessary, and really ensuring that there is that cross collaboration and educating families about what those risks are.

We just shared just a moment ago that there's a formal screening that goes through so that families who are not eligibl are then referred to, you know, higher risk care as needed.

And I don't want to gloss over that there are risks in birth in childbirth, there are risks.

I don't want to gloss that over at all.

I just want to be clear tha the risks tend to be outweighed when we talk about the risks of home birth and midwives versus the risks of medicalization.

Right now, more tha 85% of births in this country.

I'm sorry, right now more than 85% of maternal deaths in this country are preventable, and those are not at the hands of midwives.

Those are in hospitals and are medical interventions.

And that is not to put the blame there either.

The systemic issues around our maternal mortality crisis are complex.

And so I just want to be careful when we talk about risk and safety, that we are encompassing all of the issues that come into play and the complexity of the issues, and that we help educate and inform birthing people and families about what their— what their options are, and trust that they're going to make the best choices for themselves and for their family.

And what are the risks?

Because we haven't really talked about that.

What are the biggest risks if you decide to bring your child into this world with the help of a midwife as opposed to an OB-GYN?

Midwives are trained to— Midwives view birth as a natural physiologic process.

And it doesn't need like a continuous intervention and monitoring and medicalization and less intervention is better.

That's how we view birth and we have sometimes complications happen.

And when those complications happen, we need the hospitals.

We need the OBs.

So the risks are—so in the community setting, midwive care for low risk pregnancies.

And when there is issue that come across the pregnancy then maybe consultation happens.

Maybe collaboration.

Collaboration and co-care with another provider would happen, or complete referral would be the other option.

And there is risk and pregnancy a pregnancy that started normal, that was a low risk pregnancy might end up having complications.

So you can't say 100% like there is a risk when you are going with a midwife versus there is a risk that when you— when—there is no risk whe you are seeing an obstetrician because it's a dynamic thing, things change.

So generally midwives are trained to care for low risk pregnanc and obstetricians are there to manage the complications, to do C-sections and other stuff.

So the safety would be, again, having that syste of collaboration so that we can do things in our scope.

Because I have— I may have a client who is pregnant now, who I'm caring for, and and then they might end up having some complication or some issue.

And if there is a collaboration, then I'm talking with the obstetrician or whoever is responsible for the care that the client is needing, so that the client receives the proper care from both of us sometimes.

And then maybe I might refer this client to the hospital, and if they end up having a C-section, then I can continue providing postpartum care so the client can have like a continuum of care across the pregnancy and acros the lifespan, for that matter.

It does—it's not necessarily only pregnancy.

And we provide care out of pregnancy too.

So we do need that system.

And we can't sa hospital is safe because we have this increasing maternal mortality where majority of the families are now having their babies in hospitals.

And no people have started to say, no, we want to have bodily autonomy, we want to have our options.

We want to consider what birthing options we have, what providers are available to care for us.

And then that's why they are choosing, like to have their babies in a birth center and at home because they feel safe and they feel cared for and they— and there is no unnecessary intervention that comes wit having your baby in a hospital.

So people need like enough education to choose their birthing options depending on their personal belief, depending on the conditions of their pregnanc and depending on their income, because that also matters and other factors.

Now my closing question is to both of you, are there successful methods for screening all potential complications and eliminating people from doing in-home births if they have risks that other women don't have?

And are those being used?

We have risk assessment protocols and each midwife may practice differently but midwives receive the proper education and training to do their risk assessment as they are caring for their clients.

And the way that we have general consensus on that, that we receive through education.

And there is no like a hard- core yes and no thing.

It's an ongoing assessment.

It's—this risk assessment starts from when your client is interviewing you as a midwife, and it continues throughout pregnancy.

So there is— it's not like one thing.

Midwives do this throughout the pregnancy.

Each prenatal care the client comes to you.

You do your risk assessment continuously during pregnancy, during birt and after they had their baby.

This risk assessment continues.

So and there is no like a hard line saying you are a low risk pregnancy.

You will have your baby and you are high risk an you have to go to the hospital because things change continuously.

And we just need like the system of like the—for the flow so that we can care for our clients, both in the community and in the hospital so that the client have like a continuous support throughout the pregnancy and birth and postpartum and after they—after, like that time of postpartum also.

Okay.

Thank you both so much fo a very enlightening discussion.

And we will continuously look into the issue of home birth, because it's an interest to so many American mothers and fathers.

That's it for this edition.

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