Fabulous resource on state homebirth midwifery laws and their impact on homebirth mortality rates

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Lana Muniz, PhD has prepared a fabulous resource on state midwifery laws and their impact on homebirth mortality rates.

Muniz wanted to know whether stricter regulation of homebirth midwives leads to better outcomes.

Using the CDC Wonder website, U.S. neonatal mortality rates (NNM) are examined for term, singleton births attended by non-nurse midwives in out-of-hospital settings. States are grouped by regulatory status, and NNM of those groups are compared to assess whether state midwifery laws have an impact on out-of-hospital birth mortality.

Not surprisingly, more regulation of homebirth midwives and greater adherence to the regulations leads to lower risk of perinatal death at homebirth.

States which require midwives to be licensed have a 30% reduction in NNM below the national average. States which also require malpractice insurance (only Florida during the study period) have a 50% reduction in NNM, though this result does not quite reach statistical significance at the 5% level.

The impact of requiring collaboration or a low-risk scope is unclear due to small sample size. The RR for scope has a large confidence interval, and the collaboration study is highly correlated with the malpractice insurance study; Florida births comprise over half the collaboration study group. Thus, there is insufficient data to conclude whether collaboration and low-risk scope have an impact on NNM.

However, it is clear that mandatory malpractice insurance is the most important driver of safer outcomes at out-of-hospital births, for it cuts neonatal mortality in half. Requiring malpractice insurance and collaboration did not appear to restrict access to out-of-hospital births, since nearly 10% of out-of-hospital births under study were in Florida. However, even with these regulations, the mortality rate in Florida (RR: 1.83) is almost double that of births to hospital midwives.

state midwifery laws

You can find the whole report below:

 

You can download the entire report here.

Kudos to Muniz for the massive amount of work that went into this and for the valuable information that resulted. This will help women make better decisions about the risks of homebirth.

  • Nancy

    The table shown above is incorrect. You have NY listed as needing “Collaboration.” This law was change din 2010 to allow midwives to practice independently. No collaboration agreement is needed for home birth or hospital midwives any longer. Since this law was changed years ago yet your article was written only a few months ago, it makes me wonder what else is incorrect in your table?

    • Lana Muniz

      The criteria for the collaboration group is simply a written collaboration agreement with a state licensed physician or CNM. I’m aware that the NY law was relaxed, but it still meets the minimum criteria for the purpose of my study.

      From http://www.op.nysed.gov/prof/midwife/midwifeqa.htm:

      “17. What is the relationship between licensed midwives and physicians?

      Licensed midwives are not supervised; they are independent practitioners. New York State law provides that licensed midwives shall have collaborative relationships with:

      a licensed physician who is board certified as an obstetrician-gynecologist by a national certifying body; or

      a licensed physician who practices obstetrics; or

      a hospital, that provides obstetrics through a licensed physician having obstetrical privileges at such institution, that provide for consultation, collaborative management and referral to address the health status and risks of his or her patients and that includes plans for emergency medical gynecological and/or obstetrical coverage.

      A midwife shall maintain documentation of such collaborative relationships and shall make this information available to his or her patients.”

      • Linda Rosa

        Lana — Has your study been published anywhere?

  • mikerbiker

    As a resident of Virginia, I was shocked to see that the chair and vice-chair of the Midwifery Advisory Board are both CPMs. http://www.dhp.virginia.gov/medicine/advisory/mw/

  • I wonder how many women commenting here showed up to the Missouri State legislature?
    You know, in reference to HB 2189
    🙁

    • Bombshellrisa

      It would be amazing to see our regulars all there-and quite a journey for most of them (me included).

  • Kitten_Kitten

    Point of clarification- there is no such thing as “alegal” midwifery. Either something is lawful or it isn’t. If there is not a midwifery license issued from a dept, within a state licensing agency, allied health board, or independent board midwives practicing in that state are illegal. Perpetuating this myth makes it confusing for mothers choosing home birth.

    • Bombshellrisa

      I agree, but the myth is being perpetuated by the midwives
      “midwives are “alegal” in our states. They are neither licensed nor prohibited, so we practice openly, secure in the knowledge that the state cannot touch us because we aren’t violating any laws. As long as we don’t do anything that someone might interpret as the practice of medicine, we feel pretty safe. How can we be prosecuted for practicing midwifery when midwives are not prohibited?” This is from the opening of “From Calling to Courtroom” http://www.fromcallingtocourtroom.net

    • Ash

      Haven’t there been cases in “alegal midwifery” states where the court found that a woman was being paid for midwifery services but there were no charges? I think that’s what most “alegal” midwives are counting on.

  • Young CC Prof

    You know who might want to see this? The Missouri state legislature. Earlier this year, a bill to require malpractice insurance was introduced there, but didn’t make it to the floor.

    It’s HB 2189, and the sponsor is Diane Franklin.

    • YES! Lord have mercy, I KNOW Diane Franklin.

    • So Diane is the State Rep for the district in MO where I grew up, and where my parents still live. Her husband has practiced family medicine forever, and actually use to share a practice with my family doctor growing up (who, side-note, actually took a medical hiatus as a member of the MO House of Representatives for several years before settling back down as a Hospitalist at the Regional Medical Center)!
      Anyway, I’ll make sure Diane sees this fabulous study stat!

    • Lana Muniz

      That’s the bill they were considering when Dreah Louis testified: http://dreahlouis.blogspot.com/2014/04/missouri-hb-2189-metting.html

  • L&D RN

    Does anyone have a well-written letter about this all ready to go to their state representative that you’d be willing to share?

    • Not at the moment, but I think it’s something I’m going to work on over the next several days!

  • Elaine

    That “signed the birth certificate” business could be tricky. There is a practice of CPMs in my area (they are alegal in my state) that outright stated they do not sign the birth certificate, you are expected to go file for it on your own. What are the odds that there are other non-nurse midwives who do this too? Some data will be missing from this dataset.

    • The Computer Ate My Nym

      That’s an important limitation on the data. So far, basically all the limitations identified have been in the direction of underestimating home birth mortality. And yet home birth mortality is higher. This is information that pregnant women trying to decide what to do when they go into labor need to know.

      • Therese

        It seems like that might overestimate it. If the baby is just fine, Mom goes and finds someone else to sign the certificate. However, if the baby dies, I don’t know that it’s clear the midwife would be able to get out of signing it because then the legal authorities would have gotten involved and perhaps they would insist it be signed by the midwife presiding? Not sure.

        • The Computer Ate My Nym

          I don’t see any way that the mother could force the midwife to sign the certificate. I suppose it might happen, but I suspect that in at least some of those cases, the mother has to go to the state to register the birth which is then listed as unattended.

        • Elaine

          I think more likely if the authorities are called to the home and the midwife is there, she will claim to be a doula, trusted friend, etc. And they are probably pretty careful to make all sorts of CYA statements about how mom births at her own risk, they are not official legal birth attendants, etc. Ugh.

  • Kq

    I thought it was perinatal mortality that was the key indicator? Not that I doubt her findings, but for clarity? An awesome report btw, very impressive!

    • Lana Muniz

      Perinatal mortality (the first week of life) is a better indicator, but neonatal mortality (the first month of life) is a decent proxy. Dr. Grunebaum used neonatal mortality in his published study that I used as a model.

      • Kq

        Thanks so much! I really admire the work you’ve done.

      • The Bofa on the Sofa

        Have you sent this Grunebaum yet?

      • fiftyfifty1

        To clarify what you had to say about Perinatal Mortality:

        Perinatal mortality as the number of deaths in the first week of life PLUS the number of stillbirths from 22 completed weeks onwards, per 1,000 births.

    • fiftyfifty1

      Yes, perinatal mortality paints a more complete picture than neonatal mortality, but the CDC Wonder doesn’t collect this data. If it did, the homebirth picture would look even worse because we know that homebirth midwives often let their patients go far over their due dates. But when babies die in utero due to this, they are not captured in the CDC Wonder set because they are stillbirths, not live births.

  • The Computer Ate My Nym

    One minor criticism: The comparison to the national in hospital mortality rate is not perfect. For example, Florida’s mortality rate is a bit lower than the national average, meaning that Florida’s out of hospital mortality rate is a bit worse relative to its in hospital mortality rate than it appears. It would also be interesting to know whether the demographic characteristics of the mothers varied between in hospital and out of hospital births. (This criticism is not meant to denigrate the author’s excellent work, only to suggest limitations and potential future directions for further research. Also, are you planning to submit this or have you submitted this for peer review publication? I’d suggest you consider doing so.)

    • Lana Muniz

      National in-hospital mortality is 0.41/1,000.
      FL in-hospital mortality is 0.40/1,000 (RR: 0.98, CI: 0.80-1.18).

      This supports the claim that insurance is the cause of reduced out-of-hospital mortality and not some other factor making birth in FL generally safer than the rest of the country.

      Though, in general, there is variability in the state-level hospital NNM. I would expect this is due to maternal demographic/socio-economic differences between states. This is probably not an issue in the homebirthing population, which is mostly white and middle class (so I’m told).

      • The Computer Ate My Nym

        I got a slightly lower number for Florida, but only looked at the most recent set of data. Anyway, thanks for the clarification!

  • fiftyfifty1

    Let me make sure I am remembering the CDC Wonder data correctly:

    The data in this report does NOT include babies born accidentally at home or unassisted homebirths.

    The CDC Wonder rates UNDERESTIMATE death rate at home because homebirth disaster transfers are counted in the hospital stats, not the home stats.

    Correct?

    • Lana Muniz

      These are birth outside a hospital in which a non-nurse midwife signed the birth certificate. 98% of these births were in homes or in birth centers. 2% are in other locations, and ideally I would have removed them from the sample, but that’s not possible with the Wonder website.

      And yes, this does underestimate death rates because transfers to the hospital are counted as hospital births.

  • Trixie

    I will be writing to my state representative today! Thanks Lana! This is amazing work!

  • Amy M

    Well, it COULD help women make better decisions about the risks of homebirth, but how many homebirth advocates will a)be aware of its existence and b) even if they are, accept the facts? To some of those people, evidence means “whatever I feel to be correct” and if there are any inconvenient facts, they are ignored, and anyone trying to convince them otherwise is an idiot who hasn’t done her research or a shill for Big Medicine/Pharma/Whatever conspiracy theory.

    Knowing that malpractice insurance would significantly improve outcomes is not what the homebirth midwives want to hear, and they will ignore it. Women shopping around for a homebirth midwife will be hard-pressed to find one with malpractice insurance, even if they are aware that the midwife should carry it. How many want a homebirth badly enough to ignore the fact that the midwife has no insurance?

    Then its all hunky-dory until a disaster happens, and then the homebirth community turns on the grieving mother and tells her she should have done her research. Her fault for not knowing that midwife already killed 7 other babies in 4 states, under 3 different names. I truly hope this (excellent) data will change someone’s mind. Maybe another midwife will do the right thing and get insured. Maybe another woman who wants a homebirth will insist on getting care from a licensed midwife with insurance and if she can’t find one, then she’ll go to the hospital.

    • The Bofa on the Sofa

      I think this is a good point. For example, how many people even KNOW there is a difference between a CPM and a CNM in the first place, much less whether there is regulation or insurance or oversight?

      • anon13

        Another great place to post this article would be via Doula Dani at her BabyMed column.

    • Lana Muniz

      My target audience is state legislators. I think some could be persuaded by stats like this.

      • Amy M

        That would be great! You mean persuade them to pass some legislation requiring that home birth midwives be licensed and carry insurance? What about oversight? Their current MANA and NARM organizations seems to be doing a terrible job.

        Do you think legislation like that will lead to a high rate of compliance and improvement in homebirth stats? Or is it more likely to drive the (poorly trained) CPMs out of business and possibly allow for some kind of home birth system with CNMs like in Canada or the UK?

        • Lana Muniz

          It seems to me that an insurance company, by their own financial interest, does a better job of regulating midwives than state governments do. I think requiring insurance would improve outcomes, there would be fewer deaths, and loss families would have some recourse.

        • Lana Muniz

          I’d like to point out that even ACNM doesn’t have safety standards for their members who attend homebirths. I wouldn’t count on any professional midwifery organization to start having safety guidelines until their members are being sued.

          • Amy M

            I’m totally supportive of your goals, by the way, just skeptical that even mandatory insurance will be able to bring some of these crazies to heel. But I agree with your point below about the insurance companies regulating the midwives. Anyway, I guess there will always be some “underground” population of rogue midwives and their clients, and the loss families there suffer most….but if they had access to a lot of homebirth midwives with insurance, and chose an uninsured one anyway, that’s kind of on them.

          • Ash

            My state has licensed CPMs and also has a publicly funded technical college that has a CPM program, so unfortunately I am skeptical that it will be possible to eliminate licensed CPMs entirely any time in the near future.

            I do think it’s possible for the scope of practice in my state to be further restricted. For example, at the moment, multiple gestation and breech required a physician consult but is does not prohibit the CPM from attending the homebirth. Positive HIV test requires consult, but they are only prohibited if they have AIDS (we all know it’s possible to be HIV+ but not AIDS. still, no one HIV plus should have a CPM attending a HB). Also no restriction on premature and postdates. MANAstats and an abundance of other evidence indicates that prohibiting CPM attendance of multiple gestation, breech presentation, and premature/postdate labor could make these births more safe.

            I doubt the legislature has the guts to prohibit attendance of TOLAC at home, although that should be done too.

          • Guest

            What is the curriculum? I’d love to know…

          • Ash
      • Amazed

        Welcome here, Lana! Thanks for the wonderful, EVIDENCE-BASED job you’re doing. I followed your participation in the discussion under the ridiculous “documentary” MANA pulled out of their you know what and wondered whether you were one of us here. Once again, welcome.

        • Lana Muniz

          It’s thanks to Dr. Amy’s posts that I even knew about the Wonder website or MANA hiding their death rates.

      • fiftyfifty1

        Here’s a question for you Dr. Muniz, although maybe it is outside the scope of this study,

        What do we know about the rates of choosing homebirth in the various states? Because it is clear that requiring malpractice, as Florida has done, is correlated with an improved homebirth death rate. But what about just making homebirth midwifery illegal as AL, DC, GA, HI etc have done? Sure their homebirth death rates are worse than in other states, but perhaps this is offset by the fact that making homebirth midwives illegal might discourage women from doing a home birth at all, and so in the end babies are saved?

        I know this is a complicated question, because homebirth rates vary from state to state based on a number of factors such as cultural expectations. But I guess what I am asking is, is there evidence that making homebirth midwifery* illegal reduces homebirths?

        * to clarify, making homebirth MIDWIFERY illegal does not mean that homebirth is illegal. It just means that it would be illegal for a midwife to hire out her services. A woman could still deliver at home, accompanied by whomever she chose, but no $ could change hands over it.

        • Trixie

          Homebirth midwifery is illegal in many states, where it still happens.

          • fiftyfifty1

            So in those states does the CDC Wonder data show a bunch of out of hospital births where the mother files for the birth certificate herself and where she claims it was “unassisted”? For example if we had 2 side-by-side states, one where it is legal and one where it is illegal, do we see the same rate of OOH births but just that the birth certificate is signed by a homebirth midwife in the legal state and the certificate is signed by mom as an “oops happened at home” in the other state? Or does the illegal state have a total rate of OOH birth that is lower?

          • Trixie

            I think it probably depends on *how* illegal it is. In my state, lay midwifery is illegal, but yet they practice with impunity. I’m looking at the state birth certificate requirements and it looks like “other” persons in attendance can file birth certificates. I really doubt anyone is cross-referencing birth certificates filed and trying to prosecute CPMs with that info, because they can’t even bring them to trial for things like neglecting to treat group b strep.

          • Lana Muniz

            Those birth certificates would be in the group attended by Others, along with births attended by taxi drivers, which are not included in this study. In Illegal states, I found there were 23,000 births attended by illegal midwives who signed the birth certificate, and their death rate is the worst!

        • Lana Muniz

          I believe what you are asking is whether licensing midwives increases access to home births and increases the absolute number of deaths, offsetting the gains from a reduced mortality rate. Florida has a lot of home births, but it also has a large population. One of the checks I did, not in the study, was to calculate excess mortality per capita. This quantity is roughly double in Illegal states compared to Florida. I think the regs in Florida have contributed to weeding out the “bad apples,” either forcing them out of practice or forcing them to practice more safely.

          • Trixie

            Or just causing them to move to other states where it’s easier to be a rogue midwife.

        • An Actual Attorney

          Do you mean CPMs or all home birth services? I’m curious, because I know a number of women in DC who have had home births, I thought with cnms

          • fiftyfifty1

            I don’t know the details of what is legal in DC. I was going off of Dr. Muniz’s chart that says it falls into “illegal”.

          • Lana Muniz

            This study only includes non-nurse midwives. They are illegal in DC, according to NARM: http://narm.org/pdffiles/Statechart.pdf

    • Amy

      While this is definitely a good point, remember that there are loads of people who never post but do read both home birth advocacy sites and this site. Often because the home birth sites whine so much about how mean Dr. Amy is. Those people will see the link to this report, too, and have one more resource to make a more informed decision.

  • The Bofa on the Sofa

    So overall still 3 times the rate of hospital midwives…

    Although I’d advise Lana to be more careful with her significant figures. See for example the 95% confidence range for the illegal midwives. With 58 deaths in 23225 births, it’s not justified to claim precision of 0.01 in the RR, because you can’t have a relative rate of 4.66 – 7.87. The closest is 4.73 – 7.88 (45 – 75 deaths), so the proper range should be 4.7 – 7.9

    It is important to pay attention to little things like this.

  • The Computer Ate My Nym

    Interesting. It looks from these results like legalization, regulation, and requiring malpractice insurance is the way to go. Though I note that even the strictest regulation does not result in survival rates that are comprable to those in the hospital.

    • Anj Fabian

      That is to be expected. Even the best prepared, most experienced and educated midwife is only one person working in a resource poor environment.

      Compare the solo attendant working at home to the staff of an entire L&D unit.

      Compare the equipment the attendant brings with her to a home birth with the massive resources that a hospital unit has.

      You will get excess morbidity and mortality due to the discrepancy in resources. The question should be “What are the best possible OOH outcomes given this lack of resources”. That’s the target.

      However, it will require quite a lot of resources to get that best possible outcome. Two CNM level attendants. Risking out patients. Limiting OOH locations to those close to a high resource hospital.

  • toni

    This is great, well done to Dr Muniz.

    Surprised to learn FL is the only state requiring malpractice insurance.

    • Lana Muniz

      Recently, IN began requiring insurance. But there are a lot of states who license midwives and don’t require it.

    • AlexisRT

      And yet, Florida does not require it for OBs.