Does professional licensing ensure safety of homebirth?

On the exact same day, two prominent individuals within the homebirth community expressed diametrically opposed views on the licensing of homebirth midwives*.

According to Victoria Brown, founder of North Carolina Friends of Midwives:

“Women are going to have home births whether this is legal or not – those CPMs are legal or not.”

Licensing CPMs would mean more accountability with midwives, Brown said.

“It’s a public health issue to make sure there’s a standard of practice,” Brown said.

But across the country in Oregon, Melissa Cheyney Chair of the state Board of Direct Entry Midwifery asserted the opposite:

“I don’t think licensure guarantees safety…”

In 2008, Cheyney did a study [on Oregon midwives]. “I looked at [birth outcomes] for licensed and unlicensed midwives, and there was no big difference,” she said.

Cheyney is opposed to the bill for several reasons. She pointed to the new administrative rules governing direct entry midwives that the Board adopted in January. These rules “protect a mother’s right to choose while also protecting her safety,” she said.

More importantly, Cheyney is concerned that requiring licensure could actually have an adverse effect on home birth safety by “driving midwives underground, and not voluntarily participating in peer review and other things they currently do.”

Although they different on licensing, Brown and Cheyney appear to agree on one critical point. Homebirth midwives have no intention of following the law. They practice when they are legal and they practice when they are illegal. Evidently they believe that laws are for other people, not for them.

Professional licensing (for any profession) is fundamentally an issue of public safety. The primary purpose of licensing is to standardize the qualifications for practice and create a mechanism for regulation of the professionals to be sure they adhere to standards of practice. But homebirth midwives aren’t interested in public safety. Even those who support licensing blithely acknowledge that homebirth midwives routinely ignore laws and regulations.

For homebirth midwives, the issue of licensing is all about, and only about, money, specifically how much more of it they can put into their pockets. Once you understand that, it is easy to understand the difference of opinion between Victoria Brown and Melissa Cheyney. In North Carolina, midwives are not eligible for insurance reimbursement unless they are licensed. In contrast, Oregon unlicensed midwives are eligible for insurance reimbursement. North Carolina midwives want licensing because they want insurance money. Oregon midwives already have insurance money and other considerations are irrelevant to them.

I tend to agree with Melissa Cheyney that licensing does not improve the safety of homebirth midwifery. That’s because both licensed and unlicensed homebirth midwives are grossly unqualified to provide care to anyone. Moreover, as both Brown and Cheyney cheerfully acknowledge, homebirth midwives don’t bother to follow the law, so licensing laws are meaningless. Finally, most midwifery regulatory organizations are toothless. The state may set standards, but the the licensing boards, comprised of homebirth midwives themselves, refuse to punish those who ignore the standards.

For some strange reason, though, both Brown and Cheyney think it is perfectly acceptable for homebirth midwives to flout the law, any law, regulating homebirth midwifery. And perhaps even more bizarrely, they think that homebirth midwives’ disregard for the law means that we ought to change the law. That makes about as much sense as declaring that since criminals will rob banks anyway, we might as well open the doors to the safe hoping to minimize injuries during robberies.

We don’t do that, though, when it comes to robbery. Instead we increase the penalties for violating the law. That prevents a lot of bank robberies. The response to homebirth midwives flouting the law should not be to make it easier for them to profit from providing substandard care to women and newborns. The response should be to dramatically increase the penalties for violating the law. That’s what ensuring public safety requires, but for homebirth midwives, the safety of the public is last and least among their concerns.

*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australian midwives who have university degrees.